It’s no secret that the COVID-19 pandemic has had a tremendous impact on the U.S. healthcare system. Testing facilities and hospital emergency departments have experienced disruptions, and both clinicians and administrators have had to scramble to meet both the operational and clinical challenges of the pandemic.
Revenue cycle management teams are being asked to help their organizations regain financial footing in the wake of the economic effects of the pandemic. Hospitals have seen declines in revenue related to preventive care and elective procedures. The ability to recoup different types of financial losses will be critical to remaining fiscally solvent.
Becker’s Hospital Review recently spoke with Christopher Hart, chief product and strategy officer at eSolutions. He discussed challenges facing healthcare providers related to Medicare underpayments and the role that technology can play in overcoming these obstacles.
Note: Responses have been edited for length and clarity.
Question: Hospitals have taken severe revenue hits during the pandemic. What opportunities exist for providers to recoup some of those losses?
Christopher Hart: The good news is that the federal government — through the Coronavirus Aid, Relief, and Economic Security Act — has provided over $100 billion in relief funds to help hospitals and other healthcare providers recoup some of their losses. As part of the CARES Act, the federal government requires commercial insurance companies to reimburse healthcare providers for any COVID-19-related care.
More importantly, the CARES Act has also made funds available for uninsured patients with a COVID-19 diagnosis. Those funds are administered by the Health Resources and Services Administration. Although funds are available for the uninsured, healthcare providers must attest that they have made every effort to ensure that these individuals don’t have an individual or employer-sponsored health plan.
It’s critical that healthcare providers remain in compliance with this provision of the CARES Act. The key to success is having a good insurance discovery workflow in place prior to submitting patient claims.
Q: Why do Medicare underpayments occur and what solutions are available to help hospitals receive adequate reimbursement?
CH: Medicare underpayments can happen for a variety of reasons. When eSolutions works with hospital customers on underpayments, we start with the Medicare Inpatient Prospective Payment System, or IPPS and the many programs Medicare makes available to hospitals to ensure they are being appropriately paid for the care they deliver.
One of those programs is Transfer DRG. This program relates to a subset of DRGs for which Medicare underpays hospitals in anticipation of patients moving to a post-acute setting for continued care.
If for any reason the patient doesn’t go from the hospital to the post-acute care provider, the hospital can edit the claim, resubmit it and receive additional reimbursement for the care they have already provided. But failing to identify these patients and resubmit the claims is a systemic problem across the hospital sector.
If hospitals aren’t diligent and don’t watch patient flow outside of their four walls, they can end up leaving money on the table. I want to stress, however, that this is not the fault of the hospital business office. It’s the result of patient behavior.
Q: With multiple technology solutions available, how can hospital leaders ensure they’re investing in solutions that will best meet their organization’s needs?
CH: When it comes to Medicare Transfer DRGs, several companies can help providers get paid appropriately. Not all vendors provide the same level of service, however.
To correctly and accurately handle transfer DRGs, organizations must have access to Medicare’s Common Working File for information. You want to make sure you’re working with a vendor that is a Network Service Vendor or NSV. Those vendors are credentialed by Medicare to securely exchange information with them.
When selecting a technology to help with transfer DRGs, hospitals must keep an eye out for vendors that impose unnecessary operational requirements on the organization. Inside the hospital, the medical record is considered the ‘source of truth.’ For Medicare, the source of truth is the Common Working File. Vendors often spend too much time sharing and extracting medical records, when all they really need to do is to focus on the Medicare Common Working File to identify the claims that need editing.
Transfer DRG solutions should provide a touchless experience. A partner like eSolutions can extract the information needed to identify claims that Medicare underpaid and then edit those claims on behalf of the hospital. Once implemented, our solution is entirely touchless, hospitals never have to send us files and we provide ongoing review to ensure the hospitals approves every claim before it is adjusted.
Redundancy is also critical. We always encourage hospitals to contract with multiple Medicare Transfer DRG vendors, even if they are administering a program themselves. It’s like sweeping the floor — every time you do it, you will find a little bit more. These gains come down to the fact that each vendor approaches the problem a little bit differently.
Q: For revenue cycle management teams that are motivated to eliminate underpayments, what barriers might prevent teams from achieving success? How can they overcome these obstacles?
CH: If healthcare providers are really interested in finding and eliminating Medicare underpayments, the first step is to look at Medicare’s claim adjudication system, which is called the Fiscal Intermediary Shared System.
This system contains considerable information that can help revenue cycle management teams. However, many Medicare systems are difficult to navigate. FISS is no exception. Tools are available that can help healthcare providers systematically gather data, generate human readable reports and create workflows to find and resolve claims that need attention.
Q: Hospitals have limited resources and, now more than ever, must be incredibly judicious with every major transaction. What should hospital leaders look for in vendor partners to ensure they get the most out
of their investment in technology solutions?
CH: The first thing hospital leaders should consider is whether or not their technology partners are really taking sufficient time to understand the organization’s problems and ask if partners are tailoring their solutions to address those problems.
The second key consideration is whether the vendor will take the time to onboard and train team members so they can use the tools appropriately. For eSolutions, training isn’t just a point in time activity. It’s an ongoing exercise that happens over the life of our relationship with our clients.
Conclusion
Looking ahead, there’s little doubt that the current economic environment will continue to be difficult for hospitals and health systems. The reality is that many organizations are stretched too thin operationally.
While Medicare underpayments are a challenge that isn’t going away, the good news is that many emerging revenue cycle management tools and processes are proven to achieve more accurate levels of reimbursement. Trusted Medicare network service vendors like eSolutions can help organizations get a grip on Medicare Transfer DRGs, MBIs, eligibility verification and claims correction.
“Many organizations recognize the importance of revenue integrity and are launching programs to address the issue, but they just don’t have the resources to make them a success,” Mr. Hart said. “Working with a partner like eSolutions that specializes in revenue integrity can augment these initiatives and ensure that providers are paid every dollar for the care they deliver.”