In the near future, hospitals will compete for business just like other service industries, i.e., restaurants and retailers, to name a few. For example, consider how someone finds the best speaker to buy on the market. They go online and compare prices, specs and quality. Knowing this information, they can then decide whether they will choose a certain speaker or not. For years, healthcare was immune to this level of consumerism, but since the push for stricter price transparency laws in healthcare, the consumer now has all the information they need to choose your hospital or not. The truth this change brings is that consumerism isn’t going anywhere. In fact, it is only going to get ramped up. As it will affect their bottom line, hospitals should take this seriously and plan to align with consumer demands and expectations.
Of the various factors that impact your healthcare organization’s profitability, pricing is an often overlooked lever that you have control over. Even those healthcare organizations that do address pricing sometimes undermine their strategic pricing strategies by failing to address lesser-of-charge clauses or skipping the charge description master (CDM) modeling process, which can wreak havoc on their bottom line. The price transparency mandate added another layer of complexity, as raising prices to eliminate lower reimbursement may have adverse effects.
During the height of the COVID-19 pandemic, patient volume declined by 60%, overall claims volume decreased, and revenue plummeted for healthcare organizations and hospitals nationwide. However, insurers were paying for virus treatment and testing services, which helped offset some of the financial impacts of the epidemic.
In July 2023, CMS proposed some major price transparency changes with the release of the 2024 OPPS rules. Most notably, the proposed rule changes move to standardize the formatting of the machine-readable files (MRF), increase data accessibility and greater accountability. This can lead to a significant impact on hospitals that are not completely compliant with existing regulations. Even if you believe your organization is 100% compliant today, the proposed changes may expose your hospital to penalties. Let’s examine the proposed price transparency changes and highlight how PMMC is quickly moving to incorporate these changes to help our clients remain compliant.
The CMS’ hospital price transparency laws are in full effect. In addition to requiring hospitals to post pricing data online, these regulations also make it mandatory for facilities to provide estimates to patients upon request and include estimates for ancillary providers as well.
Contract modeling software can help healthcare decision-makers look beyond their revenue cycles and adapt to industry trends to maximize profitability. Partnering with an experienced contract modeling system provider like PMMC is also helpful for evaluating payer contracts and ensuring that they’re being fully maximized. Let’s further examine contract modeling software, including why hospitals need them and the benefits they provide.
Over the last several years, hospitals and healthcare groups have been ravaged by pandemic-related revenue losses. According to the American Hospital Association, in 2021 alone, U.S. hospitals lost approximately $54B in net income. Despite that, hospital leaders strive to achieve an economic resurgence by reducing operating expenses, streamlining operations, and perhaps most importantly, restructuring payer proposals to maximize their returns.
Most hospitals have been feeling the effects of ongoing staffing challenges. Hospitals across the nation are struggling to hire and retain both frontline care providers and administrative talent like accounting personnel.
Since early 2020, hospitals have been contending with unprecedented challenges that have negatively impacted their revenue and profitability. Throughout 2022, 53% of hospitals had negative margins, according to the American Hospital Association, and even those projected to end the year with positive margins are still recouping from the financial hurdles of the last few years.
A revolutionary new AI tool is poised to change how healthcare organizations manage revenue recovery and protect cash flow.
We would like to congratulate April Miller, Director of Contracting and Payor Relations at PMHA, as PMMC's Star of the Month!
We would like to congratulate Sheila Morris, Revenue Cycle Director at Shepherd Center as PMMC's Star of the Month!
We would like to congratulate Sylvia Palomo,Payer Compliance Manager, Managed Care Contracting at Texas Children's Hospital as PMMC's Star of the Month!
We would like to congratulate Mary Bongiornio, Director of Admission and Financial Clearance at MetroHealth as PMMC's Star of the Month for January!
We would like to congratulate Gina Aiello, Chargemaster Specialist at Saratoga Hospital as PMMC's Star of the Month for November!
Insurers are swimming in data that gives them a steady stream of insights into their markets and the healthcare providers with whom they contract. Unfortunately, most providers don’t have access to the same level of business intelligence. That lack of reliable information on payer performance puts healthcare organizations at a disadvantage.
The Chargemaster (CDM) review is one of the most important initiatives for a hospital prior to the new fiscal year and requires a balancing act between price transparency demands and net revenue impact. It's a huge undertaking and if you manage the Chargemaster at your hospital, your team is likely small with limited resources. This action plan is designed to help guide the way and ensure your next Chargemaster review is successful!
According to the American Hospital Association, the financial impact to hospitals from COVID 19 has been about $200 billion over the last four months, or about $50 billion a month.
It’s no secret that negotiating payer contracts has always been a challenge for healthcare providers. With the recent shift toward consumerism, changing patient behavior, and the revenue fallout from the COVID-19 pandemic, uncertainty is at an all-time high. To address this uncertainty, PMMC brought together four Managed Care experts. And we do mean experts – every panelist has had at least 25 years of experience. The panelists didn’t hold back from addressing the real challenges our hospitals face today in terms of revenue and reimbursement. It was shocking to learn that from March 1 to April 15, hospitals were losing $1 Billion per day due to the drop in elective procedures during the height of the COVID-19 outbreak. In just one hour, we covered everything including how to handle this revenue loss with payers, the impact of the rise in telehealth, and how to use predictive analytics and scorecards to manage and predict all these shifting dynamics in reimbursement.
As people across the country have shifted to working from home due to the COVID-19 outbreak, hospital revenue cycle leaders are doing their best to maintain "business as usual" while recognizing that they face unique challenges. PMMC recently hosted a virtual roundtable with two revenue cycle leaders at AnMed Health (based in Anderson, SC) and The Shepherd Center (based in Atlanta, GA). Our goal was to provide a forum for revenue cycle leaders to share their challenges and best practices for managing a team remotely and keeping up with payer collections. With over 100 healthcare providers in attendance, Samantha Evans from AnMed Health and Sheila Morris from the Shepherd Center offered some great advice and really spoke to what revenue cycle leaders are going through during this difficult time. Below you will find background on our revenue cycle panelists and their responses to the roundtable questions.
For healthcare providers looking to make improvements to their revenue cycle, they should consider how they plan to manage their payer contracts and all of its data.
What are the Pros and Cons of contract modeling software versus using Excel for modeling and negotiating payer contracts? Negotiating payer contracts is one of the most important functions of Managed Care within hospitals and health systems. When done correctly, new contract terms can sometimes save healthcare organizations millions of dollars in reimbursement.
With over 400 hospitals and health systems nationwide equipped with the latest revenue cycle management (RCM) software through an integrated platform, PMMC is recognized as a leading provider of RCM software and services.
The healthcare revenue cycle is used by hospitals and health systems to manage all of the administrative and clinical data that comes into the hospital every day.
We live in a fast-paced digital world where literally every second, data is being shared from person to person across various networks. Because of this shift, businesses need to have access to the latest and greatest technology for not only serving their customers directly but also to allow their own employees to improve the financial performance of their company.
Just when we thought CMS was finished updating the requirements for the new price transparency ruling, they release another FAQ list that provides additional clarification to certain questions and includes new items to be added to your list of standard charges.
According to the CMS mandate (also referred to as FY 2019 IPPS/LTCH PPS), hospitals will be required to post their standard charges online via a machine-readable format for any given service by January 1, 2019. These prices must be updated at least annually and no hospitals are exempt from this mandate.
In August 2018, the Centers for Medicare and Medicaid Services (CMS) provided additional clarification to the new healthcare price transparency ruling (referred to as FY 2019 IPPS/LTCH PPS) that requires hospitals to post their standard charges online for any given service. The details of this mandate are spelled out in a series of frequently asked questions (FAQ) published on the CMS website.
At a time when healthcare consumers expect greater personalization when it comes to receiving price estimates, providers are feeling the pressure to improve price transparency by providing an online patient estimation solution that is engaging, easy to use, and most of all, accurate.
What is the CMS Price Transparency Final Rule? In an effort to increase price transparency for consumers, CMS has updated its guidelines under the Final Rule CMS-1694-F (which is part of FY 2019 IPPS/LTCH PPS) that requires hospitals to post standard charges online in a machine readable format. This will be required for all hospitals beginning January 1, 2019.
During our recent webinar session “Denial Management Essentials: The Metrics and Reporting Tools You Need to increase Revenue” we polled healthcare providers on several topics around denial management.
During our recent webinar session “Winning Strategies for Contracting in Narrow Networks” we polled healthcare providers on several topics around narrow networks. These questions provide insight as to how well your organization is prepared to manage narrow network negotiations. How would your healthcare organization answer these questions? Here’s how the live webinar attendees responded… 1. Is your organization currently part of a narrow network?
At a time where the healthcare industry is forced to adapt to new reimbursement models, providers are having a tough time adjusting to the contract negotiation process. Each reimbursement model comes with its own stipulations and understanding how to work with the payer to reach your organization’s financial goals comes with its own set of challenges.
Laying the Foundation
Every profession has its set of experts. In the health industry’s managed care field, one of those experts is Susan Mego.
Revenue, Cost, Productivity and Quality: The Four Modern Day Healthcare Directives Heard in Today’s Boardroom
All across the modern day healthcare landscape in hospital and healthcare system boardrooms, the four main topics discussed on a regular basis by executive leadership are focused on these business issues:
For hospitals contemplating revenue cycle solutions, it’s important to make sure your revenue cycle solutions aren’t half-baked. Have you ever bought a bunch of ingredients and gadgets to duplicate what the pros make on a cooking show? They make it look easy…but it’s not. There are nuanced skills with timing, technique, temperature, and other subtle variables related to sequence and presentation. Cooking shows are similar to industry consolidation; be it energy, automotive, or even healthcare. So, what do we get with consolidation?
This webinar has taught us a lot about a program in the healthcare industry commonly referred to as narrow networks. We learned about the pros and cons for adopting this type of system, the growing trend of employers offering this to their employees, and most importantly, the value of knowing the contracted terms before entering into these agreements. So, with that being said, what’s the biggest piece of advice we can take away from this presentation?:
During our recent webinar session “Intro to Narrow Networks: What’s the Impact on Healthcare Providers?” we polled healthcare providers on several topics around narrow networks.
Narrow Networks have become increasingly popular among providers looking to provide patients with a comparable quality of care at lower premiums. Here's a look at some stats showing its current success rate:
The path toward financial stability for healthcare organizations can be a bumpy road. Due to a surplus of big data, providers can utilize this information to search for any areas (aka. opportunities) where they can lower their costs by working together to create a solution that all parties can agree on. This process usually requires some give-and-take from both sides but the goal is to find new innovative means of lowering their costs, without sacrificing the quality of patient care.
Much of the rhetoric surrounding mandatory bundles has been negative and defensive – i.e. how do healthcare organizations deal with these programs to prevent risk and avoid financial penalties to CMS?
Click here for a 20 minute intro session to Narrow Networks.
What We Learned (Part 3): Q&A "Adapting to New Reimbursement Models: How to Maximize Payer Performance and Maximize Revenue"
During the HBI webinar "Adapting to New Reimbursement Models: How to Maximize Payer Performance and Maximize Revenue," attendees had an opportunity to ask the speakers questions about how these lessons can be applied to thier own healthcare organization. Here is a recap of the questions and answers given:
During the recent national webinar session “Adapting To New Reimbursement Models - How To Measure Payer Performance And Maximize Revenue” we polled healthcare providers on several topics around value-based reimbursement contracts and payer performance and monitoring.
What We Learned (part 1): 7 points on new reimbursement methods that every revenue management team needs to know
Webinar recap: "Adapting to New Reimbursement Models: How to Maximize Payer Performance and Maximize Revenue"
Webinar: Adapting to New Reimbursement Models- How to Measure Payer Performance and Maximize Revenue
At a time where the healthcare facilities are constantly adapting to accommodate an influx of reimbursement methodologies, tracking your payer performance has never been more important. With these methodologies becoming increasingly relevant in today’s modernized healthcare system, it’s important to study them until you know them like the back of your hand.
What are the Methods of Hospital Reimbursement? Discount from Billed Charges Fee-for-Service Value-Based Reimbursement Bundled Payments Shared Savings For healthcare financial staff, some cycles are so common they are taken for granted – day and night, seasonal changes, month-end close, year-end reporting. On one hand there is the age-old adage, ‘the only constant in life is change’ and on the other hand ‘the more things change, the more they stay the same’. When providers approach the task of monitoring payer reimbursement, the doctrine of cycles certainly apply.
Due to complications with timing, the Centers for Medicare and Medicaid Services (CMS) has delayed implementation of the three new episodic payment models (EPM) and Cardiac Rehabilitation (CR) incentive program until January 1, 2018.
Executives in the healthcare industry are constantly looking for more accurate ways to manage and balance their pricing strategies.
It’s no secret that healthcare prices have skyrocketed over the last 20 years. It seems like everyone has a personal story (or knows someone) who has had sticker shock for a healthcare service.
There’s no denying that Big Data is everywhere in our day-to-day lives. By some estimates, there has been more data created in the past 2 years than in all of human existence combined. The rapid evolution of technology is aiding the vast amount of choices we have in the consumer world to leverage machine learning in an effort to study our habits and predictively deliver what we are looking for, when and where we need it.
CMS called a timeout this week on some of their mandatory bundled payment programs. But that doesn't mean the value-based reimbursement game has been cancelled.
With tens of thousands of line items and hundreds of carve-out clauses in fee-for-service and percentage of charge contracts, managing reimbursement terms with government and commercial payers can be a tough task if you don’t have the right tools. Just like anything else.
Hospital denial management staff must understand who their "problem" payers are, which billing habits may be causing delays, and know exactly how much money the payer owes in order to better manage denials and drive cash back to the bottom line.
We live in a modern world where businesses have grown increasingly competitive. It doesn’t matter if your business is small or large, new or already established. And the healthcare industry is no exception.
We're pleased to announce that PMMC has been selected by JFK Health, based in Edison, NJ, for bundled payment analytics to manage the costs for the Comprehensive Care for Joint Replacement (CJR) Model.
Be sure to join PMMC next Tuesday, October 18th for a webinar featuring The MetroHealth System, to learn how they are navigating price transparency requirements by offering online, self-service patient estimates.
We know revenue cycle teams are very busy and often managing competing priorities. So what are their top initiatives today? A recent survey of 93 senior healthcare finance executives provides some insight. According to the survey from Connance and Porter Research, senior healthcare finance executives are more likely to implement updated IT and hire additional staff than contract with outside consulting services in order to optimize revenue cycle workflows.
We're pleased to announce that PMMC has been selected by Cabell Huntington Hospital (CHH) for contract management and denial management.
One of our most forward thinking clients, The MetroHealth System (based in Cleveland, Ohio), will share its experiences with consumerism, price transparency, and patient financial communications during an HFMA webinar next Tuesday, August 30th.
Despite efforts to improve price transparency, 43 states received an "F" grade according to the Health Care Incentives Improvement Institute (HCI3 ) – Catalyst for Payment Reform (CPR) Report Card on State Price Transparency Laws.
Las Vegas is the place to be next week (June 26-29) for healthcare finance and the revenue cycle at the annual HFMA National Institute (ANI). PMMC will be front and center in the exhibit hall, so be sure to visit us at Booth 123.
It’s a disadvantageous situation from the beginning: It’s time to renegotiate payer contracts, but your hospital has a high volume of commercial contracts and payers are shifting to new reimbursement methodologies. Not to mention the contract language is open to interpretation.This is a situation Managed Care is placed in more and more often these days. These factors give leverage to commercial payers and make it difficult for hospitals to determine how the new contract terms impact net reimbursement revenue, especially when using tools like Microsoft Excel.
It's estimated that nearly 7% of healthcare providers claims are denied by payers. The good news is that nearly 75% of these items can be successfully appealed and collected. However, this process is tedious and, more importantly, extremely time consuming for staff. Some payers are notorious for denying claims more frequently and are slower to pay than others. State Medicaid programs are known to be one of them. Medicaid state programs are among the slowest paying and least transparent payers, with an overall average denial rate of 18.5 percent (compared with 6.8 percent for all payers) and an average of 44 days spent in Accounts Receivable (compared to 26 days for all payers).
Did you know that 80 percent of patients find a patient estimate to be helpful, but only about 25 percent of patients actually receive one?
No April Fools joke here. Medicare's Comprehensive Care for Joint Replacement (CJR) ruling officially goes into effect TODAY in 67 markets leaving many hospitals accountable for the total cost of services across the entire episode of care for hip and knee replacements. The financial risk for hospitals is between $500,000 and $3 Million in payback penalties over the next five years. That's a lot of money.
This is not an early April Fools joke. Medicare's Comprehensive Care for Joint Replacement (CJR) officially goes into effect on April 1st in 67 markets (the specific MSA's can be found at the bottom of this post), leaving many hospitals accountable for the total cost of services across the entire episode of care for hip and knee replacements. That's why we're partnering with Healthcare Business Insights (HBI) on March 15th for a webinar to help hospitals prepare for the financial impact of the CJR model.
From New York to Los Angeles and in between, researchers found it difficult, frustrating, and sometimes impossible to obtain patient estimates for routine medical procedures, according to a new study from the Pioneer Institute Policy Brief. Here's the scenario: Researchers called into 54 hospitals in six metropolitan areas (Des Moines, IA, Raleigh-Durham, NC, Orlando, FL, Dallas-Ft. Worth, TX, New York, NY and Los Angeles, CA) asking for the price of an MRI of the left knee. Generally speaking, this is a pulse check of how far healthcare providers have advanced in adapting price transparency.
Hopefully your hospital's pricing strategy doesn't sound like this: “Prices were set in cement a long time ago and just keep going up almost automatically.” This was one Chief Financial Officer’s explanation of Chargemaster prices from the controversial 2013 Time Magazine article “Bitter Pill: Why Medical Bills Are Killing Us.” The article highlighted the extreme cases of high prices at hospitals and even called several hospitals (by name) into question. Although some of the findings in the report were later disputed, the article placed hospital pricing under a microscope and reinforced the need for defensible pricing. Automatic price increases might be the traditional route, but the strategy opens itself up to scrutiny, inefficiencies, and a potential loss in net revenue. Because of these factors and the recent emphasis on increased price transparency and defensible pricing, hospitals are moving away from the "across the board" annual gross price increase and towards a modeling approach to predict how charge adjustments impact net revenue. Not only does this give finance a clearer picture of future net revenue, it creates a defensible pricing strategy if prices ever come into question.
We now have a better understanding of the financial implications of the Comprehensive Care for Joint Replacement (CJR) model, the new CMS rule that requires bundled payments for hip and knee replacements.
“The health care system suffers from an overabundance of paper work” is how the American Hospital Association (AHA) begins its January 2016 Trendwatch report.
Significant Changes Coming - Get Ready Now On November 16, 2015, The Department of Health and Human Services (HHS) announced that CMS has approval for the final rule for the Comprehensive Care for Joint Replacement (CJR) Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services . It will be applicable in April 2016. CJR is the first mandatory bundle model, and it represents the prototype for massive change in healthcare finance that will take place in the next two years.
As expected, the Centers for Medicare & Medicaid Services (CMS) finalized the Comprehensive Care for Joint Replacement (CJR) model, which will hold hospitals accountable for the total quality of care they deliver to Medicare beneficiaries for hip and knee replacements from surgery through recovery. The announcement came in a news release on Monday.
There is a lot of discussion about Price Transparency in Healthcare across our country. Many state legislatures are getting involved, including Florida. Recently, Florida Governor Rick Scott announced he will encourage (some might say push) state legislation to require hospitals to post their prices for procedures and services as well as their average reimbursement on the hospitals' websites in early 2016.
Florida Governor Rick Scott is not backing down on his push for price transparency for health services.
Florida Governor Rick Scott thinks so and he wants to add legislation to put an end to it.
As patient responsibility continues to grow, point-of-service collections become increasingly important. According to a recent HFMA article, two-thirds of patients are consistently surprised by their bills and only 25 percent are proactively counseled about their cost of care. In response, hospital revenue cycle processes need to account for the shift in payment responsibility.
The Centers for Medicare and Medicaid Services (CMS) loves to use acronyms and there’s quite a few related to its new CCJR bundled episode payment model. For healthcare finance professionals, it’s easy to lose sight of some of these, so we’ll recap and break them down with definitions:
By now, most healthcare finance leaders are at least familiar with the recent CMS Comprehensive Care for Joint Replacement (CCJR) Model. This is a really big deal for healthcare providers. Let’s start with the basics:
Remember the days of waiting in line at the airport to actually have someone check you in at the counter? Those days are long gone in the airline industry, as airlines have adapted self-service kiosks, and more recently, mobile check-in to expedite the process even further. But this self-service model is still in the infancy stages in other industries, like healthcare.
Hospital pricing has come under intense scrutiny over the past several years, from both government legislation and media attention. The pinnacle of the media coverage came in 2013 when Time Magazine released “Bitter Pill: Why Medical Bills Are Killing Us.” The article highlighted the extreme cases of high prices at hospitals (i.e. patients getting charged $1.50 for single aspirin or $74 for a roll of gauze). Because of the recent pressure towards increased priced transparency and defensible pricing, hospitals are moving away from the traditional annual gross price increase.
The hospital contract management system is the key to maximizing financial performance, minimizing risk, and ultimately managing all aspects of payer contracts to get reimbursed accurately. However, it’s becoming more and more difficult to predict reimbursement. As third-party payers shift from a “fee-for-service” or “percent-of-charge” reimbursement model to value-based reimbursement, contract terms, coding, and their interpretations inevitably become more complex.
Here’s a frightening statistic: Only 2.5% of companies successfully complete 100% of their projects. The reasons why, you ask? Requirements – Unclear, lack of agreement, lack of priority, contradictory, ambiguous, imprecise Resources – Lack of resources, resource conflicts, turnover of key resources, poor planning Schedules – Too tight, unrealistic, overly optimistic Planning – Based on insufficient data, missing items, insufficient details, poor estimates Risk – Unidentified or assumed, not managed