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

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.  

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. 

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.

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:

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.

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

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.

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.

The specifics: The FDA recently approved a 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. 

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.