The overall goal of revenue integrity is to ensure compliant documentation as it relates to charging practices across the healthcare industry. The roles within revenue integrity departments range from employing staff within charge description master (CDM) maintenance to expanding staff within charge capture. This includes staff within clinical departments responsible for adequate charge reconciliation, charge entry, and denials management and remediation staff, such as Physician Fee Schedule (PFS) and coding and billing departments.
With the release of the price transparency rule in 2021, many hospital organizations were faced with the impact of pricing on patient care and patient choice. Many patients do not know or understand the complexities of the healthcare reimbursement, so they are now faced with the choice of pricing out how much they will pay for services. Hospitals that do not comply with the final rule can be fined between $300 and $5,500 per day, depending on the hospital's size.
Source: Hospital Price Transparency, CMS.gov
It is important for health information management (HIM) professionals and for members of the revenue cycle to understand that the role of revenue integrity is changing. The market is becoming more consumer-driven, and healthcare organizations are desperately working to recover the financial losses from elective services being delayed or canceled during the pandemic.
Although most organizations are experiencing exponential growth, it is important to understand that organizations are required to provide correct financial data related to the top healthcare services they are providing in the facility. The CDM is the primary resource that is utilized to evaluate and provide this information to ensure compliance of the price transparency rule. Since the CDM provides all the fees that go out on the facility claim forms, ensuring that the information is updated on the CDM consistent with the current financial practices of the organization is vital to the success and compliance of the price transparency rule.
According to an article addressing information related to the price transparency rule, “The Kaiser Family Foundation (KFF) analyzed data from the two largest hospitals in each state … although 80% of the hospitals provided gross charge information on the required machine-readable file and the price estimator tool, only 35 of the 102 hospitals displayed payer-specific negotiated rates.”
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) made some updates to the Q&A section of the price transparency rule. Quite a few questions that weren’t addressed during the initial implementation were answered in this Q&A document. This includes information related to “whether hospitals can post average charges, and how hospitals should display payer-specific negotiated charges when no standardized dollar amount applies to the members of the health plan.” Be sure that your CDM and the members of your organization are ensuring compliance with this rule by reviewing this Q&A document and the hospital price transparency site often.
Additionally, payers were required to post their charges effective July 1, 2022. This is known as the Transparency in Coverage rule, and it requires health plans to post pricing information for covered items and services. This information can be used by consumers to understand the costs associated with their healthcare, as well as by researchers and application developers to help consumers better understand healthcare costs. More requirements are slotted to go into effect on January 1, 2023, and January 1, 2024.
Although the payer plan transparency may be separate from what we face within our healthcare organizations and medical facilities, the overall message is true. Healthcare is slowly becoming a consumer-driven market. How is your organization going to cater to the new generation of healthcare decision-makers? Ensuring that we are equipped to demonstrate our commitment to our patients and these new CMS regulations is vital to ensure that our patients can obtain the care needed in the most cost-effective manner possible.
Jennifer Foskett is a health information management professional, local speaker, and the owner of medicalcodingformillennials.com, a blog about deploying her HIM experience into business intelligence insights. In her current role as a revenue integrity manager, she challenges HIM professionals to look at the business of healthcare from a holistic lens.