The Intake

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Vital Signs: A May 2024 wrap-up of revenue cycle management healthcare news

This month’s ‘Vital Signs’ covers cyberattack difficulties, RPM code discussions, and significant telehealth coverage expansions

This post is a part of the Vital Signs series
Diagram depicting claims care rcm

At a Glance

  • Independent medical practices are struggling with verification and claims processes due to the Change Healthcare cyberattack, leading some doctors to use personal savings to stay afloat.
  • A class-action lawsuit against UnitedHealth Group over algorithmically facilitated denials may be dismissed, which could impact Medicare Advantage denials and the use of AI in payment decisions.
  • Despite discussions, there will be no changes to remote patient monitoring codes for now, with potential updates to be revisited in September 2024.

Welcome to “Vital Signs,” your go-to monthly digest of all things related to RCM tailored specifically for independent practices. You can access previous editions for the top insights and developments here.

There’s always an abundance of revenue cycle management (RCM) news to report, and this month is no different. We’ve got topics ranging from algorithmically facilitated denials to expanded coverage and reimbursement of virtual care, social risk assessments during the annual wellness visit, and more. Here’s a roundup of newsworthy RCM stories from May 2024.  

1. Independent medical practices continue to suffer from the Change Healthcare cyberattack

The specifics: A recent survey from the American Medical Association (AMA) found that medical practices continue to face challenges in verifying patient eligibility, submitting claims, and receiving electronic remittance advice and payments in the wake of the Change Healthcare cyberattack.

Why it matters: Experts say the effects of the attack are crippling these practices, some of which are led by doctors who have dug into their own personal savings to stay afloat.  

What’s next: Continue to monitor the AMA’s website for updates and advocate for national health officials, state governors, and Change Healthcare/UnitedHealth Group to take more action to help physicians who have been impacted financially. Also, consider taking proactive steps to protect patient health records and other data from cyberattacks against your medical practice. 

2. UnitedHealth Group says algorithm lawsuit should be dismissed

The specifics: UnitedHealth Group hopes a class-action lawsuit involving algorithmically facilitated denials will be dismissed because it says plaintiffs failed to exhaust the exclusive administrative appeal process set by the Medicare Act, a process that can often take years and potentially drain the finances of Medicare beneficiaries and their families who decide to pay for care on their own while they wait for a resolution.

Why it matters: Medicare Advantage denials continue to plague healthcare providers and patients alike.

What’s next: Monitor the outcome of this case closely, as it could have a ripple effect throughout the industry in terms of whether and how payers can leverage artificial intelligence to deny payment.

3. Remote patient monitoring code changes stalled for now

The specifics: FierceHealthcre recently reported that despite a “tense” discussion during the AMA’s CPT Editorial Panel meeting in May, there will be no changes to codes for remote patient monitoring (RPM) for now.

Why it matters: As we reported last month, changes to these codes would have provided two different billing options for remote monitoring based on how many days of data a provider collected:

  • 2-15 days’ worth of data collection lowering the threshold for payment
  • 16-30 days’ worth of data collection likely with higher reimbursement

What’s next: Stay tuned for the September panel meeting, during which members may revisit the proposed RPM changes. That meeting will be held September 19-21, 2024.

4. AMA provides tips to help cut EHR burdens for physicians

The specifics: In this article from the AMA, experts provide several tips to improve EHR workflows, including the following:

  • Identify specific pain points for physicians using the EHR.
  • Understand regulatory requirements and quality goals that impact EHR use.
  • Prioritize EHR changes based on impact, feasibility, and clinical needs.
  • Decide where to automate, delegate, and collaborate.
  • Remove items that don’t add value.

Why it matters: During times of increased physician burnout and administrative burden, taking these steps can greatly improve physician well-being and efficiency.

What’s next: Complete this exercise in your own medical practice. Then work with your EHR vendor to make any necessary changes, adjustments, and improvements.

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5. Significant progress has been made in expanding widespread use of virtual care

The specifics: A recent report comparing telehealth laws in 50 states before and after the Public Health Emergency reveals a significant expansion of coverage and reimbursement for telemedicine and digital health technology. For example, 18 states passed audio-only telehealth laws to make such coverage permanent for health plans. As of 2024, 33 states now have laws on payment parity or reimbursement rates, up from 16 states in 2019.

Why it matters: Lack of coverage and reimbursement has been one of the biggest barriers to telehealth adoption, and this report shows that this barrier is gradually eroding.

What’s next: Stay tuned for continued expansion of coverage and reimbursement. However, note that certain telehealth waivers may expire on December 31, 2024. Contacting your senators and representatives to urge the permanent adoption of statutory telehealth waivers is critical.

6. New FDA decision expanding use of Wegovy could affect Medicare coverage

The specifics: The FDA recently approved new use for Wegovy (semaglutide): to reduce the risk of heart attacks and strokes in overweight or obese people with cardiovascular disease. This decision could have significant implications for Medicare, which is currently prohibited by law from covering Wegoy and other medications when used specifically for obesity. 

Why it matters: An estimated one in four Medicare beneficiaries with obesity or overweight could be eligible for Medicare Part D coverage of Wegovy to reduce the risk of serious heart problems. 

What’s next: Keep an eye on Part D plan coverage announcements. The new FDA-approved indication for Wegovy could pave the way for broader coverage by other insurers as well. 

7. MLN Matters article addresses new SDOH assessment as an optional AWV element

The specifics: Medlearn Matters article (MM 13486) reminds providers that they can now bill separately for a social determinants of health (SDOH) risk assessment when performing it as part of an annual wellness visit (AWV). To do this, report HCPCS code G0136 for the SDOH risk assessment with modifier –33, with the same date of service on the same claim as G0438 or G0439.

Why it matters: Before January 1, 2024, Medicare didn’t cover and pay for an SDOH risk assessment. This means physicians can now take advantage of this new revenue opportunity while simultaneously improving patient care. 

What’s next: Familiarize yourself with the coding and billing nuances of this service. For example, when you provide the SDOH risk assessment as an additional element of the AWV, you must do it in a way that’s appropriate for the patient’s educational, developmental, and health literacy level. 

The assessment must also be culturally and linguistically appropriate. When you provide the SDOH assessment as an additional element of the AWV, patient cost sharing, Part B coinsurance, and deductible doesn’t apply. Note that the SDOH assessment also requires 5-15 minutes of time with the patient, not more often than every six months. There are other requirements as well, so be sure to review them prior to billing.

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Lisa Eramo, freelance healthcare writer

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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