If You Haven’t Done a Post-PHE AR Reset, It’s Time

If You Haven’t Done a Post-PHE AR Reset, It’s Time

Think back to what your AR processes looked like before the COVID-19 pandemic – how much do they have in common with the way your medical billing accounts receivable processes look today?

If they’re too similar, I’m sorry to say that your organization is likely falling behind the challenges facing medical providers today. And that’s because things have changed for providers – both internally and externally. Medicaid disenrollment is ramping up, junk health plans are on the chopping block, and CMS is adjusting to a new world. Internally, you’re probably coming off of years of adjustments to shifting patient volumes, changes to your staffing and technology, and keeping up with the ebb and flow of government programs. Everything has changed – and your approach to medical billing accounts receivable processes should have too. If not, your revenue cycle health is at risk.

It’s time for an AR reset, and there are a few things revenue cycle leaders can do today to make sure you’re on top of the changes you face.

  • Determine the last time you evaluated AR processes: If you’ve been keeping up with your approach to AR, congratulations, you’re ahead of the game. But if you haven’t had a refresh since 2021 or earlier, it’s time to reassess.
  • Assess the level of sophistication of your AR: There’s no reason to get stuck in the past. Take some time to evaluate where your AR processes stand today so that you have a strong awareness of your starting point.
  • Check the last time your KPIs were refreshed: You can’t manage what you don’t measure. If there’s any initiative or concern that your organization is prioritizing but you don’t have associated KPIs, it’s time for a refresh.
  • Review ownership and responsibility: Who owns your AR? Who’s responsible for making the most important decisions? Are they supported in navigating the coming challenges? If this isn’t something you’ve looked at since the height of the COVID-19 pandemic, you’re overdue for a refresh.

It’s most important though that you view this as an opportunity – a chance to bring your AR processes up to date so your organization can take advantage of fast-coming changes in healthcare. If you want to learn more about the possibilities that lie in front of you, feel free to contact me.

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.

Pediatric Medicine’s Struggle with Labor Shortages and Other Limitations

Pediatric Medicine’s Struggle with Labor Shortages and Other Limitations

Pediatric medicine supports some of the most vulnerable members of society. This makes shortages in the space even more concerning. Unfortunately, the same shortages of resources and professionals that plague the rest of the healthcare industry also impact pediatric medicine.

For leaders in this area, it means having to free up revenue so they can invest in solutions through options like working with pediatric medical billing companies or examining their relationships with pediatric medical billing and coding services.

To help you understand the forces that are driving these considerations, we’ve compiled some of the top challenges in pediatric medicine today.

Pediatric Hospital Beds Are Limited
Today, the number of hospitals that offer pediatric services has dropped from 42% a decade ago to just 37% [1].

For at least 10 years, the number of pediatric beds available has been trending downward. As of 2018, one in four American children were traveling greater distances for a bed compared to their trips in 2009, according to the journal Pediatrics. This was largely due to a decrease in the number of children who needed care before the COVID-19 pandemic. Compared to 2017, 2019 saw around 200,000 fewer pediatric discharges. But overall, care has improved in helping children with conditions like cystic fibrosis and sickle cell, and prevention has improved for problems like meningitis and pneumonia through vaccination programs.

As anyone working with pediatric medical billing and coding services will know, pediatrics is seasonal, with patient numbers falling in the summer and rising again during respiratory virus season in the winter. But, at the beginning of the pandemic, daycares and schools closed, which meant COVID and other infectious diseases were spreading more slowly among children, decreasing the need for hospital beds. In many cases, beds that had been dedicated to children were shifted to care for adults. 

Childrens’ Hospitals Are Struggling
Nursing shortages have hit some of the most vulnerable providers. Even before the COVID-19 pandemic, children’s hospitals were being threatened by workforce shortages. Nursing school enrollment was falling short while at the same time, there was a shortage of faculty to help train new nurses. Some hospitals have even reported retirement rates that doubled in 2021. Many nurses were working through the pandemic, enduring waves of shortages, then inactivity. In the midst of all this, they were deciding as to whether it was a good time for them to finally leave the workforce. Just like nurses in general, nurses in the children’s hospital space want work life balance and are taking advantage of opportunities in contract work. 

The nurse turnover rates for Children’s hospitals are severe. According to data out of PROSPECT, a leading financial and operational data set in pediatrics, the quarterly turnover rate increased more than 76% for registered nurses when comparing the first quarter of 2019 to quarter three of 2021 [2]. The critical shortage of pediatric nurse practitioners has been a point of concern as far back as 2019. 

These hospitals have also reported that travel nursing is especially effective in luring nurses away since it allows nurses to pay off student loans and other debt. This means that for hospitals to stay competitive, they should be willing to increase pay rates. This is a good reason for children’s hospitals to consider pediatric medical billing services to help ensure that their cash flows are as healthy as possible and that they have strong revenues to provide the higher compensation that is attractive to pediatric nurses. 

Pediatricians and Pediatric Specialists Are Hard to Find
The country is facing a shortage of pediatricians. As far back as 2021, it was estimated that the US could experience a shortage of thousands of physicians in pediatrics [3]. Some states are having particular struggles, such as Florida, which has a worsening need for pediatricians. 

Pediatric medical subspecialists are critical to the health of children since they treat patients with special needs. When there are shortages of these professionals, patients have to travel long distances for care. Some wait multiple weeks or even months, sometimes skipping care or being forced to get care from providers who don’t have the appropriate training. 

The American Academy of Pediatrics reports on shortages around the country. These reports are broken down by state and include information on driving distances. Some of the subspecialties covered include [4]:

  • Pediatric cardiology
  • Pediatric infectious diseases
  • Sports medicine
  • Child abuse pediatrics
  • Neonatal-perinatal medicine

One of the potential suggestions on the fact sheet is loan repayment for pediatric subspecialists to ease access to additional training and encourage more doctors to specialize in treating children with special health needs. 

The common theme among these challenges is that forms of compensation such as pay and other financial support is important to countering these shortages and attracting talent. For providers, this means that it is critical to invest in the health of the pediatric revenue cycle today. This can be done multiple ways, including working with pediatric medical billing companies, and investing in pediatric medical billing and coding services. To learn more about how you can address these concerns, contact us today

[1] C. Zdanowicz, “Pediatric hospital beds are in high demand for ailing children. Here’s why,” Cable News Network, 17 March 2023. Available: https://www.cnn.com/2023/03/16/health/pediatric-hospital-bed-shortage-ctrp/index.html.
[2] M. M. Busenbark, “Children’s Hospitals Work to Address Nursing Staffing Challenges,” 26 April 2022. Available: https://www.childrenshospitals.org/news/childrens-hospitals-today/2022/04/childrens-hospitals-work-to-address-nursing-staffing-challenges.
[3] AAMC, “AAMC Report Reinforces Mounting Physician Shortage,” 11 June 2021. Available: https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage.
[4] American Academy of Pediatrics, “Pediatric Subspecialty Shortages Fact Sheets,” 26 March 2021. Available: https://www.aap.org/en/advocacy/pediatric-subspecialty-shortages-fact-sheets/.

News in Medical Billing and Coding Services: Surprise Billing Ruled Illegal Again

News in Medical Billing and Coding Services: Surprise Billing Ruled Illegal Again

The No Surprises Act is in the news yet again to start off 2023, promising more disruption for medical billing and coding services.

On February 6 of this year, District Judge Jeremy Kernodle issued another judgment in favor of the Texas Medical Association (TMA) – one that providers across the country will look at positively. He ruled that a revised arbitration process favors insurers and that challenges to parts of the final rule are unlawful. The president of the TMA, Gary Floyd, MD, weighed in with his opinion. “The decision will promote patients’ access to quality care when they need it most and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.” [1]

The suit, which was originally filed in September, was done in conjunction with UT Health Tyler Regional Hospital and a physician and gained the support of 30 other national and state medical groups in the form of amicus briefs. Insurers have presented the idea that providers were baseless in claiming there were “early signs of a beneficial trend, where the [No Surprises Act] has furthered good faith network negotiations over reasonable rates.” The insurance trade group AHIP, stepped out in support of HHS [1].

Previously, the TMA filed a lawsuit in October of 2021 which challenged the rule with the claim that it didn’t follow direction from Congress in implementing the dispute resolution process. It was called “short-sighted” and accused the rule of driving down reimbursement rates while encouraging insurance companies to narrow networks. It was ruled against by a federal judge in February 2022.

What Is the No Surprises Act
As this piece of legislation continues to pop up in the news, providers considering the future of their medical billing and coding services will benefit from understanding it from the beginning.

The term “surprise medical bills” refers to the situation in which insured consumers receive care from an out-of-network provider like a hospital, doctor, or provider they didn’t choose, inadvertently triggering billing they didn’t authorize. This has been found to happen in around one out of five emergency room visits. On the non-emergent care side, about 9%-16% of in-network hospitalizations have been found to potentially include unexpected bills from an out-of-network provider like an anesthesiologist the patient had no hand in selecting. These bills are an issue for patients because they often result in significant financial burden through denials or out-of-network cost sharing. Consumers are also subject to “balance billing” from providers that are out-of-network that don’t have contracts to accept discounted payment rates from a health plan. The bill potentially applies to around 10 million surprise, out-of-network medical bills each year.

This most recent news addresses the arbitration process which allows for the determination of surprise bills through negotiation between providers and insurance plans and, if negotiations are not effective, the use of an independent dispute resolution (IDR) process.

But the dispute resolution process has remained a challenge, with providers issuing more submissions for appeal than was expected. Providers have made such heavy use of the IDR process that the system has become clogged and in response, the Biden administration has raised fees for engaging in the process. In December of 2022, the Treasury Department and the Department of Health and Human Services (HHS) made a significant increase in the resolution fee, increasing it to $350 from $50 per party for each disputed claim. The goal was for the fee to be a deterrent to use. These charges went into effect January 1, 2023 [2].

Patient Impact of the No Surprises Rule
Providers who care about their medical billing and coding services and work with medical coding outsourcing companies are keeping a close eye on how the bill could impact patients. This is because patient perception impacts how they choose providers and, as more patients are aware of what the practice of surprise billing can mean for them, they will predictably weigh that in their decision-making. For example, before regulation became more intense, private equity firms were taking advantage of the opportunity to bill out-of-network services from tens of thousands of physicians which they used to staff hospitals. This included the emergency department, which left patients caught in the middle.

Impact on Provider Medical Billing and Coding Services
So, what does all this mean for providers? It means a rocky future for surprise billing and arbitration, complicating billing strategies for providers across the country. Many leaders will not only have to consider the impact of their contract negotiations, but also how their approach to medical billing will intersect with future changes in the legislation. Some providers who have already considered medical coding outsourcing companies are also looking to outsource medical billing to relieve themselves of challenging decisions as the legislative environment continues to evolve. If you are in this position and want to talk more about how the No Surprises Act could impact your organization, contact us today.

[1] J. Emerson, “Federal judge rules against HHS — again — over surprise-billing arbitration rule,” Becker’s Healthcare, 7 February 2023 . Available: https://www.beckerspayer.com/policy-updates/federal-judge-rules-against-hhs-again-over-surprise-billing-arbitration-rule.html.
[2] L. Santhanam, “How this law reshaped medical billing, and what challenges remain for patients,” NewsHour Productions LLC, 20 January 2023. Available: https://www.pbs.org/newshour/health/how-this-law-reshaped-medical-billing-and-what-challenges-remain-for-patients.

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