HFMA News

Key Takeaways for HIM Professionals at #HFMAAnnual

By Beth Friedman

The impact of new reimbursement models, egregious payer behavior, and regulatory change took center stage at this year’s Healthcare Financial Management Association (HFMA) Conference. Thousands of health care revenue cycle and finance professionals filled educational sessions and HFMA central to assess how new tactics and technologies can be implemented to combat the rising tide of reimbursement loss. HFMA panelists and presenters were candid about their relationships with payers and shared important strategies to improve the dynamic.

For example, regarding how risk-based contracts have impacted her health system, Gerilynn Sevenikar, vice president of revenue cycle at Sharp Healthcare, says, “Payers are taking advantage of providers and we’ve got to remove the friction. My hope is for technology or artificial intelligence (AI) to get us to clinical decisions we can all agree on.”

Having observed dozens of new AI vendors addressing health care revenue cycle challenges, I applaud Sevenikar’s goal. But while we wait for new tech to spark a revolution in reimbursement retention, we must also recognize our shared health care revenue cycle reality—change takes time.

Full Value-Based Reimbursement Is a Decade Away
The complete transition from fee-for-service to value-based care may be “up to a decade away” and “is taking a lot longer than anyone anticipated,” according to Kevin Holloran, MHSA, senior director and sector leader at Fitch Ratings. And as we collectively cross the divide, “cash on hand will remain the primary indicator of hospital wellness—vs operational cost cutting.”

Prioritization of revenue growth vs expense reduction has also been recognized by The Advisory Board as the top CEO strategy. In a recent survey, The Advisory Board cited improved ambulatory access to care, minimized clinical variation, stronger primary-care alignment, and redesigned health system services for population health as the top four areas of “extreme interest.” Every attempt should be made to build new revenue opportunities while decreasing risk of payer curtailments, denials, and postpayment recoupments.

Focus on Keeping the Cash You’ve Earned
Curtailing cash loss whenever and wherever possible across the health care revenue cycle was a central theme at #HFMAAnnual. Only by keeping the cash that facilities have rightfully earned can margins be maintained and doors remain open. In other words, maintain the margin while you ditch the denials.

For Peter Schmitt, CFO at MRO, denials alongside the recent rise in postpayment recoupments by payers represent the greatest risks to cash loss. “MRO is seeing an upward trend in the number of cases requested by payers for postpayment audits. So far this year, the volume of postpayment requests sent to MRO by payers is up 21% from 2018,” he says.

Extrapolated across all release of information (ROI) vendors and organizations, I estimate that over one million inpatient encounters are at risk for postpayment medical record requests and potential recoupments after the initial claim has been paid. These postpayment audits are a burden for HIM departments, but the reimbursement recouped by the payer (after the initial claim has been paid) is worse and can be up to tens of thousands of dollars. “MRO is actively working to conduct a study of these postpayment requests to quantify the costs, ascertain the trends, and identify best practices for our clients to cope,” Schmitt adds.

Of further concern to this HIM professional is that postpayment recoupments are beyond the boundaries of negotiated payer contracts. Are payers actually reaching through the fence to take back more dollars from already cash-strapped providers? I look forward to MRO’s findings later in 2019 to provide important insights and answers on postpayment recoupments, only one aspect of the total denial management picture.

Get Specific on Denials
Revenue cycle experts at MRO concur that denial and recoupment trails must be carefully monitored to close any loopholes where dollars might be disappearing. While CFOs may lump all denials into one bucket, revenue cycle and HIM professionals shouldn’t do the same. There are also significant time constraints facilities face when trying to go back and reconcile payer oversights, short pays, and egregious behavior. Day-to-day operations in the business office and HIM often supersede the need to track down a few hundred dollars recouped here and there.

MRO experts provide specific steps that HIM professionals can take to support revenue cycle peers in curbing denials—in whatever form they take.

• Collaborate on denials research. Know where your dollars are being short paid, denied, or recouped.
• Break down silos with your managed care contracting department. Provide input during every managed care contracting cycle. Ask whether contracts allow for postpayment audits, allow for appeals, and provide limits to the number of records payers can request. Participate in payer contract negotiations.
• Educate teams on payer contract terms. Support payer contract term knowledge sharing through lunch and learns for coders, clinical documentation improvement, patient access, and billing. Ensure that all revenue cycle team members understand your biggest payers’ contract terms and timelines. Knowledge is power when it comes to keeping your cash.

Include HIM in Building Positive Patient Experience
The final challenge voiced by attendees at this year’s event was how to continually build more positive patient financial experiences. For HIM professionals, this means prompt and courteous disclosure management when properly authorized and warranted. The ROI process is HIM’s most critical step in positive patient engagement. By building a positive, patient-friendly ROI process—including access to an ROI support hotline for patient questions—HIM professionals contribute to positive patient journeys and organizational reputations.

— Beth Friedman is founder and CEO of Agency Ten22 (beth@ten22pr.com).