Healthcare providers are dropping major insurers – and home health
Medical Coding Outsourcing Trend Update: Health Systems Preparing for Cost Surge with Outsourcing
Medical coding should look to supply chain leadership for guidance in navigating increasing cost pressures in healthcare.
Black Book recently released a poll of over 1,000 operations
Do You Need an SDoH Initiative in Your Medical Coding Program?
Social determinants of health (SDoH) are directly impacting medical coding, and more providers should pay attention.
Health.gov defines SDoH as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning,
Providers Are Pushing Back on Denials in Medical Billing. Is it Your Time to Join?
Healthcare providers across America burned almost $20 billion dollars in 2022 on medical billing accounts receivable – and it all went to chasing down denials and delays with payers [1]. The numbers look even more disheartening with a focus on private plans.
What’s worse is over half of that spend was wasted on claims that should have been paid when the claim was submitted – payers are burning provider resources as a stall tactic. A survey of 516 acute care hospitals found that almost 15% of all claims submitted to private payers are denied from the beginning.
This is money, time, and effort that can be better spent. Healthcare providers face the most complex revenue cycle environment in history, with advancements like AI being used against them – which is why now is the time providers should consider taking a new kind of action.
So, I was glad to see the news in July that The Health Equality Network stepped up to send a letter to CMS about the problem of medical billing denials, also including a range of congress members. Here are some of my favorite points [2]:
- “Claims are often denied without cause and lead to financial and emotional distress for individuals already burdened with the stress of healthcare issues.”
- “Medicare Advantage plans…are now inundated with prior authorization requirements and coverage denials.”
- “They (UnitedHealthcare) were sued last year for using an artificial intelligence algorithm to wrongfully deny elderly patients care.”
- “Insurance denials and prior authorization requirements affect minority and lower-income populations at a much higher rate.”
The main takeaway is that providers should focus now on tracking denials in medical billing and understanding the impact of how much money and staff time is being wasted. As more providers push back on this disturbing trend, everyone should be able to make a case for how they, their staff, and their patients are being impacted.
For many providers, doing this in an accessible and accurate way will mean outsourcing medical billing by working with a third-party vendor who has perspective on whether their investment is normal or whether they’re being taken advantage of. I am proud that 3Gen can offer this kind of support during times like these.
References
[1] D. Muoio, “Providers ‘wasted’ $10.6B in 2022 overturning claims denials, survey finds,” Fierce Healthcare, 22 March 2024. Available: https://www.fiercehealthcare.com/providers/providers-wasted-106b-2022-overturning-claims-denials-survey-finds.
[2] Healthcare Equality Network, “HEN Sends Letter to HHS Secretary Becerra and CMS Administrator Brooks-LaSure On Coverage Denials,” 3 July 2024. Available: https://www.healthcareequalitynetwork.com/hen-writes-letter-to-hhs-cms.
Hemant Apte, Chief Executive Officer in
Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
It’s Time to Adjust Your Risk Adjustment Coding Strategy
At 3Gen, we’ve talked for a while about the growing importance of risk adjustment coding—and our rationale is being proven true.
Part of the OIG’s responsibility is conducting health plan audits of Medicare Advantage organizations to identify fraud and reduce waste and other abuses of this taxpayer-funded program. The government spends more than $403 billion every year on managed care, and half of that goes to Medicare Advantage Organizations. The issue is, that as of August of last year, their audit had identified around $377 million in risk adjustment overpayments—and this number was for inaccurate coding alone [1].
This means that providers should expect more audits coming in the future—and a smart response is to get ahead of this by adjusting your approach to risk adjustment coding.
Most providers will need to focus on coding to the highest level of specificity for chronic conditions and consider coding reviews by certified risk coders to ensure accuracy. But if you want to stay ahead of the OIG, this is just the beginning.
- Make it a priority to review your current tools and workflows, looking for opportunities to supplement with outsourced risk adjustment coding where possible.
- Take time to review your health risk assessments. This will help you make sure that the diagnoses you’re billing match what patients are being treated for.
- All of these suggestions rest on the need to analyze your claims data. This will give you a strong starting point for evaluating your practices and charting a path forward.
Ultimately, the OIG is cracking down on overpayments, so prioritizing risk adjustment coding is a smart strategic focus for all impacted providers in the near term. To learn more about how your organization can build a proactive risk adjustment coding strategy, contact 3Gen Consulting today.
Reference
[1] “OIG Strengthens Oversight Strategy for Managed Care Organizations,” Healthcare Payer Intelligence, 08 August 2023. Available: https://healthpayerintelligence.com/news/oig-strengthens-oversight-strategy-for-managed-care-organizations.
Hemant Apte, Chief Executive Officer in
Hemant Apte, Founder & Chief Executive Officer of 3Gen Consulting, is a seasoned executive leader with deep domain expertise in US healthcare management practices. He founded 3Gen Consulting in 2006 and has been instrumental in offering thought leadership to his clients and providing services and solutions that are unique in the market.
