Changes to PHE waivers and recommendations for hospitals. Compliance must assist and advise on policy, process, contractual, and operational changes by May 2023.Continue reading
It’s become a cliche, especially in healthcare, to say that COVID-19 has changed “everything”. One thing that has clearly changed, however, is hospital finances.
Pandemic response stretched every healthcare system in the United States, many to the breaking point. Revenues from non-COVID procedures were significantly reduced, to the point that furloughs of vital medical staff have become necessary.
In this environment, compliance professionals have an important role to play. Ensuring that all payment compliance regulations are being followed helps to protect existing revenue streams, and helps to get the system back on a strong financial footing. As hospitals are getting “back to normal” and trying to find ways to bolster their budgets, good compliance practices are vital.
Outstanding Payments and Patient Insurance
In-hospital treatments declined during the pandemic; however, virtual health visits significantly increased. It’s crucial to continuously monitor payment compliance practices, which include patient insurance information, especially when offering this new treatment vector.
Pre-pandemic, the number of Medicare patients increased by 11 million since 2014, and at least 37 states expanded Medicare eligibility in 2019. While it’s hard to say where Medicare coverage will go as government budgets also come under pressure, these numbers could mean that some outstanding medical bills may be covered.
Historically, about 1% to 5% of self-pay accounts, or patient out of pocket costs, are written off by hospitals as bad debt. Checking and double-checking that your institution has the right information about patients, now and going forward, can be a key step in keeping the hospital financially strong.
The number of uninsured patients has continued to grow — by 12% towards the last months of 2017, and 27 million Americans have lost their employer-provided insurance during the pandemic. Overall, improving payment compliance practices in relation to insurance is an important step in effectively managing these, and other, challenges with patient payment balances.
Reducing Readmission Rates and Penalties
If your hospital serves Medicare and Medicaid patients, you probably know the high number of readmissions that occur in typical months. Readmissions that take place within 30 days of an initial visit cost hospitals a staggering $41.3 billion. In a post-COVID world, these patterns may not hold — but that could mean that readmissions are going to go up, not down.
CMS instituted several programs to try to manage these readmission challenges.
- The Hospital Readmissions Reduction Program (HRRP): rewards hospitals for lowering readmission rates for common health conditions like heart attacks, pneumonia, COPD, and total hip and knee replacement surgery
- The Hospital-Acquired Condition Reduction Program (HACRP): encourages a reduction in avoidable infections resulting from colon surgeries and hysterectomies, bedsores, sepsis, and even blood clots
Hospitals with, according to CMS, higher than average readmission rates face steep penalties and lower claims reimbursement. In the fiscal year 2020, pandemic notwithstanding, 83% of the 3,300 hospitals in the U.S. were projected to face penalties. And these penalties can be as high as a 3% reduction in repayment. Across the United States, CMS penalizes the worst-performing hospitals with a 1% reduction in total claim reimbursement.
As hospitals reopen and restart regular procedures and treatment, and try to rapidly scale revenue generation, more hospitals may face penalties, if compliance practices are not strong. Surprisingly, at least 12% of readmission cases of readmission cases are preventable, according to the Medicare Payment Advisory Commission (MedPAC).
Two ways hospitals can comply with CMS’ regulations and boost patient care are:
- Embrace a process that sends discharge summaries to the primary care physician
- Assign staff follow-up on post-discharge test results.
Setting up such a process can be tricky, especially in larger hospital facilities and in facilities that are still challenged in the aftermath of COVID. Medical staff need to be able to consistently and quickly assign, track, and review summaries and test results.
Monitoring each step of the process is necessary to ensure that your organization is taking the proper steps to adhere to Medicare and Medicaid requirements. That way, your hospital easily avoids significant penalties while boosting patient care. CMS also recommends that hospitals be on the lookout for hospital-related illnesses, which can derail patient care standards.
What You Can Do
Staying on top of the ever-changing world of CMS regulations isn’t easy, especially as we emerge from the pandemic crisis. But we can help by providing you with expert advice and tools that target the regulations and policies needed to run your hospital compliance program more effectively.
Our fully customizable software helps you and your revenue cycle team stay on top of every regulation, so you’ll have the best possible chance of meeting essential mandates, keeping cash flowing and avoiding penalties.
See YouCompli in Action
Easier, faster, more effective compliance is possible
Do you treat patients insured by Medicaid or Medicare at your hospital? While participation is voluntary for for-profit healthcare systems, accepting Medicaid and Medicare patients is a condition of federal tax exemption for non-profits. Currently, Medicare and Medicaid account for more than 60 percent of care provided by hospitals making it nearly impossible for healthcare systems to forgo these programs.
So, if the stark reality is that you must participate, compliance becomes an issue. And it’s complex. Especially for hospitals that have multiple outpatient locations and inpatient campuses. Under Medicare provider-based rules, it’s not possible to certify just part of the system. When you consider there’s nearly a 500-page certification process, it’s clear that it’s crucial to have effective compliance tracking.
An effective compliance program is multi-faceted and includes monitoring and auditing, legal reviews of procedures and contracts, reporting mechanisms as well as training for employees. Healthcare systems are multi-faceted too with labs, pharmacies, rehabilitation centers, clinics, surgery centers and more. Keeping on top of compliance not only to effectively report but to identify and then prevent misconduct before it balloons into a much bigger problem is anything but easy.
The Centers for Medicare & Medicaid Services has attempted to streamline information into quarterly updates for providers, suppliers and the public. While this helps curate the information and updates to regulations, management and oversight of compliance and putting these regs into practice represents an enormous task for each healthcare system. The distance between knowing and doing can be vast when providers are juggling regulations alongside providing quality patient care. Maintaining oversight of not just the Medicare and Medicaid federal regulations, but compliance with other state and local regulations is required.
The regulatory landscape continues to be muddled with additional requirements to safeguard privacy and to fight fraud and abuse today. Since governing bodies are vigilant about fighting fraud, your compliance process needs to be tight or you’ll risk criminal charges, fines and even the possibility of losing licenses. Every state has its own Medicaid Fraud Control Unit (MFCU), typically as part of the State Attorney General’s office. When your compliance tracking system is thorough, the auditing process and working with your MFCU becomes simpler.
Streamline Compliance Tracking
If your hospital is juggling Medicare and Medicaid payment compliance along with all the other mandates and reporting requirements, it can easily get overwhelming. But, it doesn’t have to be that way. Solutions such as youCompli’s compliance system monitors and translates Medicare and Medicaid regulations for easier understanding. Then, it helps you track and oversee your hospital’s compliance.
If you’re ready to take the headache out of Medicare and Medicaid compliance, it’s time to see what a compliance management system can do for you. Schedule a call today where you can see how our risk management software can support your healthcare system’s compliance program.