August 2024 Newsletter

We’ve assembled the latest news for healthcare revenue cycle leaders to help you stay on top of industry challenges and adapt your revenue cycle management services.

Hospitals Are Dropping Medicare Advantage

Becker’s Hospital Review reports that 16 health systems are dropping Medicare Advantage plans, an important consideration for anyone responsible for hospital accounts receivable and who wants to understand why patients might choose them as a provider. The hospitals are in multiple states around the country, including Ohio, New York, Indiana, Delaware, and Pennsylvania [1]. 

CMS Says Insurers Owe over $10.3 Billion in ACA Risk Adjustment Payments

CMS redistributed $10.3 billion in payments among insurers participating in the risk adjustment program in 2023. The previous year was $9.24 billion. While the value of payments increased, adjustment charges as a share of premiums decreased from last year [2]. 

Medicare Advantage Plans Still Under Scrutiny

Federal watch dogs are still paying attention to Medicare Advantage plans as the government cracks down on fraud across the industry. This is especially pertinent as Medicare Advantage enrollment is growing. As more providers are dropping Medicare Advantage plans, this is important news for hospital revenue cycle leaders [3]. 

CMS Published Draft Copy of the 2025 OPPS and ASC PPS

CMS has released a copy of the CY 2025 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC PPS). Included is a proposal on the implementation of Section 4135 of the Consolidated Appropriations Act, 2023. Additional proposals cover maintaining the current rate structure for IOP and PHP, Aligning OPPS payment services with Medicare telehealth, and changing Conditions of Participation for emergency and obstetric services [4].  

CMS Releases Draft Copy of the CY 2025 MPFS Proposed Rule

The agency has published a draft of the 2025 MPFS proposed rule. It proposes a direction of the conversion factor from $33.29 to $32.36. Other proposals in the rule cover new HCPCS codes, extending telehealth flexibilities, and expanding payments for opioid treatment programs, all of which the best medical billing companies are paying attention to [4]. 

Medicare Prescription Payment Plan Guidance Released

CMS has released a Memorandum announcing the Medicare Prescription Payment Plan: Final Part Two Guidance. This guidance can be helpful for physician revenue cycle management and mostly addresses enrollee education for Part D and Medicare Prescription Payment Plan communications. They’ve also included a fact sheet, timeline, and press release [5]. 

Provider Enrollment Instructions Updated

CMS published the Medicare Program Integrity Transmittal 12717 on July 18. It covers updates to enrollment topics including deactivations, denials and revocations, ownership, reassignment benefits, among others. You’ll find 112 pages of text and changes are indicated in red [6]. 

Clinical Laboratory Fee Schedule Updated

CMS has published Medicare Claims Processing Transmittal 12721 which includes the quarterly updated to the Clinical Laboratory Fee Schedule (CLFS). Anyone responsible for medical coding should check out the updates for deleted codes, new codes, and a reminder about CLFS data reporting period for clinical diagnostic laboratory tests that fall outside advanced diagnostic laboratory tests [7].

Home Health Edit Revisions Released

One-Time Notification Transmittal 12723 was released, covering an issue with home health care billing claims that include reason code 19963 in cases where the claim from and through dates might unintentionally cause purging of the NOA from systems and a resulting return of the claim in error. The transmittal is intended to implement a process that ensures these home health claims will not be returned in error [8]. 

PDPM Claim Editing Updates

CMS published One-Time Notification Transmittal 12726, rescinding and replacing 12714. This publication revises the effective and implementation dates to split the CR with the October release. This is so FISS can start work on this CR in the October release. Professionals responsible for healthcare accounts receivable management should know that the update goes into effect on October 1, 2024; January 1, 2025 [9].