Hospitals and healthcare organizations – many of which are still responding to tremendous financial losses and staffing shortages resulting from the COVID-19 pandemic – are under intense pressure to maximize revenues and minimize compliance risks. As 2022 gets underway, the team at MDaudit is looking ahead to the top trends that will affect medical billing and billing compliance this year.
Fee schedule updates
From telehealth services to shared E/M visits, there are many significant changes in the 2022 Medicare Physician Fee Schedule (PFS), finalized by the Centers for Medicare and Medicaid Services (CMS) on November 2.
One simple provision is additional time in the face of the ongoing pandemic. CMS has extended until the end of 2023 reimbursement for the Medicare telehealth services list previously adopted to respond to the COVID-19 public health emergency (PHE).
Elements of the PFS regarding telehealth reimbursement for mental health services may prove to be a little less straightforward. For example, audio-only communication technology may now be used in some circumstances for providing telehealth services to established patients for the diagnosis or treatment of mental health disorders, but only when delivered by providers who could provide two-way, audio/video technology, but instead used audio-only technology due to patient’s preference or technical limitations. They must attest to this capability using a new modifier for such services.
A modifier will also be required for split E/M visits – those delivered jointly in a facility setting by a physician and a non-physician practitioner (NPP). The bill must be submitted by the physician or NPP who provides the substantive portion of the visit. For 2022, CMS has defined “substantive” as history, physical exam, medical decision-making, or more than half of the total time. By 2023, the definition will be limited to simply more than half of the total time spent.
CMS continues to evaluate policies for E/M visit code sets, which signals even more changes ahead.
Prepayment reviews
Private insurers are expected to follow Medicare’s lead in relying more heavily on prepayment reviews to identify improper reimbursements before they are made to providers.
CMS Administrator Chiquita Brooks-LaSure announced in a November press release, “CMS is undertaking a concerted effort to address the root causes of improper payments in our programs,” with a significant focus on prepayment reviews. The agency also announced that, at a projected 6.26%, the 2021 Medicare FFS improper payment rate hit a historic low and marked the fifth consecutive year it fell below the 10% threshold for compliance established in the Payment Integrity Information Act of 2019.
Commercial and public payers alike are increasingly able to leverage technology to identify issues on claims before they are paid, which reduces their administrative burden to conduct reviews while saving money that would have been erroneously sent to providers.
Increased billing compliance scrutiny by health systems and providers will be crucial to ensure timely and accurate payments.
Impacts of COVID
With 40% of all coronavirus-related claims denied in the first ten months of 2021, the ongoing changes and unpredictability of the pandemic are sure to continue causing challenges in 2022.
New variants, vaccines, boosters, third shots, anti-viral treatments, and more continue to unfold; billing and coding requirements will evolve along with them. With so many changes coming so quickly, pressure continues to mount for resource-limited health systems. It will remain critical to minimize denials and ensure claims are billed, coded, and submitted correctly.
When payers deny claims, healthcare organizations will need to employ revenue integrity processes and data analysis to understand causes and follow up in a timely manner to protect cash flow.
Changing care settings
Another trend accelerated by COVID is doing more from home. From online grocery shopping to video conference calls, technology advances and the pandemic have converged into an era in which we increasingly receive many products and services from the safety and comfort of our homes – including health care.
Virtual care is not limited to younger patients. Seniors are tech-savvier than ever and Medicare and Medicare Advantage plans are following commercial carriers in finding new efficiencies and improved outcomes by delivering virtual care to their highest risk patients. McKinsey reports that “Medicare patients are at the forefront of much of the change sweeping the healthcare industry, including shifts to virtual care delivery, more home care, and the adoption of value-based care models.”
Compliance and billing protocols must keep pace with these changes in care delivery. Many Medicare Advantage and commercial carriers, including Anthem and UnitedHealthcare, are aligning with CMS’s place of service (POS) code updates to differentiate between telehealth received in the patient’s home and telehealth delivered in another setting such as a hospital or skilled nursing facility.
What can healthcare organizations do to mitigate billing compliance risks in 2022?
- Educate. Ensure providers and coders stay informed as billing rules and regulations change.
- Predict. Deploy “revenue intelligence” and predictive analytics tools to proactively catch billing errors and avoid first-pass denial rates.
- Monitor. Meaningful audits and analysis go beyond error detection with true insights into the causes of errors and the tools to correct them.
- Manage. It’s not enough to audit if no changes are made. Implement corrective action and follow-up.
Request a demo to learn more about how MDaudit can help your audit team identify revenue and compliance risk and enable corrective action.
