With Medicare Advantage enrollment continuing to rise and more plans offering more benefits than ever, big changes are coming in 2021. This post will discuss the key changes to Medicare Advantage plans in the next year, program updates due to the COVID-19 public health emergency, and advice on how to navigate billing and reimbursement concerns.
For the first time in history, Medicare Advantage (MA) penetration has reached 40% of the total Medicare-eligible population. Currently, 25.4 million people are enrolled in Medicare Advantage (MA) plans, with a total Medicare-eligible population of 62.4 million, according to the Centers for Medicare and Medicaid Services (CMS). [ Link to report ]
With an aging population, enrollment in Medicare Advantage plans will only continue to grow (The Congressional Budget Ofﬁce projects enrollment in these plans to rise to about 51% by 2030).
Medicare Advantage is an alternative to traditional Medicare that acts as an all-in-one health plan and is sold by private insurers. All Medicare Advantage plans must provide at least the same level of coverage as original Medicare, but they may impose different rules, restrictions, and costs. Most Advantage plans offer the same A and B coverage for the same monthly premium as regular Medicare plans, but also often include Part D prescription drug coverage, limited vision, and dental care, broader coverage, lower premiums, maximum out-of-pocket limits, and extra beneﬁts—all of which expanded in 2020.
While this represents a distinct opportunity for many providers to be more proﬁtable, growing enrollment also poses challenges. Medicare beneﬁciaries have more choice than ever before when it comes to selecting an MA plan.
According to the Kaiser Family Foundation (KFF), there are 3,148 Medicare Advantage plans available for individual enrollment for the 2020 plan year—an increase of 414 plans since 2019. The average beneﬁciary could choose among 28 plans in 2020. While the choice is great for the beneﬁciary, it adds complexity to healthcare providers’ revenue cycles, who need to navigate hurdles that vary by the plan in order to get reimbursed.
MA plans also tend to be more transient, meaning patients may switch often, even yearly if they choose through the open enrollment period. Providers must better manage every patient accordingly so they can maximize plan beneﬁts. Doing so takes more effort, but the payoff can lead to proﬁt.
CMS has clearly stated a goal to move from the current fee-for-service models toward value-based care. While the Medicare Advantage population grew by 60% from 2013 to 2019, the fee-for-service Medicare population only grew by 5%. The progress Medicare Advantage plans have achieved essentially creates an idea marketplace for beneﬁciaries. Enrollment costs are down and more plans than ever are offering new, innovative beneﬁts. But what does this mean for providers?
So, how has COVID-19 affected Medicare Advantage plans? Well, the COVID-19 stimulus package, the Coronavirus Aid, Relief and Economic Security (CARES) Act, includes $100 billion in new funds for hospitals and other healthcare entities. The Centers for Medicare and Medicaid Services (CMS) made $30 billion of these funds available to healthcare providers based on their share of total Medicare fee-for-service (FFS) reimbursements in 2019, resulting in higher payments to hospitals in some states than others, according to KFF. Hospitals in states with higher shares of Medicare Advantage enrollees may have lower FFS reimbursement overall. As a result, some hospitals and other healthcare entities may be reimbursed less than they would if the allocation of funds considered payments received on behalf of Medicare Advantage enrollees.
In response to the COVID-19 emergency, many Medicare Advantage insurers waived cost-sharing requirements for COVID-19 treatment, meaning that Medicare Advantage beneﬁciaries will not have to pay cost-sharing if they require hospitalization due to COVID-19 (though they would if they are hospitalized for other reasons).
If a vaccine for COVID-19 becomes available to the public, Medicare is required to cover it under Part B with no cost-sharing for traditional Medicare or Medicare Advantage plan beneﬁciaries, based on a provision in the Coronavirus Aid Relief, and Economic Security (CARES) Act.
A Spotlight on Prior Authorization Medicare Advantage plans can require enrollees to receive prior authorization before service will be covered, and nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2020, according to KFF. Prior authorization is most often required for relatively expensive services, such as inpatient hospital stays, skilled nursing facility stays, and Part B drugs, and is infrequently required for preventive services. Prior authorization can create barriers for providers and beneﬁciaries, but it’s meant to prevent patients from getting services that are not medically necessary, thus reducing costs for beneﬁciaries and insurers.
In a 2018 analysis, KFF found that four out of ﬁve MA enrollees—or 80%—are in plans that require prior authorization for at least one Medicare-covered service. More than 60% of MA plan enrollees require prior authorization before receiving home health services, and that percentage increases to more than 70% for skilled nursing facility and inpatient hospital stays.
How Providers Can Prepare for a Medicare Advantage Boom Medicare beneficiaries have more choice than ever before when it comes to selecting a MA plan. While the choice is great for the beneficiary, it adds complexity to healthcare providers’ revenue cycle. Healthcare providers will need to navigate new hurdles that vary by the MA plan in order to get reimbursed.
When beneficiaries change plans, it creates another challenge for providers. Historically, about 10% of MA enrollees change plans during open enrollment. Although this number seems low, even a small change in coverage can cause big problems for a healthcare provider’s revenue and cash flow. Billing the wrong insurance company leads to costly denials and appeals. Becker’s Hospital Review estimates that healthcare providers spend about $118 per claim on appeals. A study by the Medical Group Management Association found that the cost to rework a denied claim is approximately $25, and more than 50% of denied claims are never reworked.
Despite the challenges, providers don’t want to be left out of the MA boom. But how can they best prepare? Well, first off, healthcare providers need to ensure they are capturing accurate patient information. Next, they need to reevaluate workflows, so they are prepared to handle time-consuming prior authorizations. Additionally, healthcare organizations must consider how frequently they are re-running eligibility on patient rosters to make certain they do not miss a change in insurance coverage for patients under their care. Providers should re-run patient rosters monthly, so they have the most accurate benefit information. This will help them avoid unnecessary claim denials.
As MA continues to ramp up, the most successful providers will be those who work with a revenue cycle management partner that understands the nuances of Medicare reimbursement as well as the added complexities of MA.
With the acquisition of eSolutions, a leader in revenue cycle technology with Medicare-specific solutions, EZClaim’s ‘partner’, Waystar, so happens to be the first technology to unite commercial, government, and patient payments into a single platform, solving a major challenge and creating meaningful efficiencies. Billing Medicare, Medicare Advantage, and commercial claims from a single platform eliminates the hassle of managing multiple revenue cycle platforms and allows providers to get deeper AI-generated insights for faster reimbursement and increased value—for their organizations and their patients.
For more information about Waystar‘s platform, visit their website, or give them a call at 844.492.9782. To find out more about EZClaim‘s medical billing software, visit their website, e-mail their support team, or call them at 877.650-0904.
If you are not a MIPS expert (Merit-based Incentive System), your Medicare reimbursements may be decreased by 9% in the next year. However, it’s not too late to avoid the penalty for the 2020 reporting period, but you need to act now!
One of EZClaim’s partners, Health eFilings’ has ONC-certified software that completely automates the MIPS compliance process for you. The software will automatically extract the required data directly from EZClaim (and/or your EHR), and then proprietary algorithms will process the 9,000,000 possible combinations of quality measures for each clinician to identify which measures should be submitted to CMS (Centers for Medicare and Medicaid Services) to earn you the most points.
Need a MIPS expert? Well, Health eFilings is one of the best, and CMS has accepted 100% of their submissions on behalf of their clients. If you have completed your 2020 reporting, reach out to them, and learn how you can earn even more points in 2021.
For more information about EZClaim’s medical billing software, e-mail, visit their website, or contact them at 877.650.0904.
[ Article contributed by Sarah Reiter, SVP Strategic Partnerships, Health eFilings]
After the examinations, x-rays, and surgeries, lives another major part of a physician’s day that happens behind the scenes. All the hard work needs to be processed through a successful claim submission, meaning that ultimately earning payment all boils down to one thing – coding. Evaluation and management codes, or E/M codes, are codes a physician uses to report a patient visit. This administrative task – a necessity for any physician – is often cumbersome and prone to errors. Most importantly, it uses up valuable time that could be better spent.
How many of us have experienced the “hurry up and wait” scenario? The type of appointment where you wait in a waiting room, then wait a little more in the exam room, then eventually get 10 minutes with your doctor…only to be rushed out so the next patient can be shuttled in. Unfortunately, it’s all too common. It’s safe to say that many patients could benefit from more face-to-face interaction with their providers.
Many people claim that payment for evaluation and management services is undervalued, specifically when it comes to ambulatory services. Additionally, it’s been argued that the fee schedule itself is not well-designed to support primary care, which requires ongoing care coordination for patients. Pressure existed to increase payment rates for ambulatory E/M services while reducing payment rates for other services. Thankfully, The Centers for Medicare and Medicaid Services (CMS) took notice. With the goal of increasing efficiencies to reduce unnecessary burdens, the “Patients over Paperwork” initiative was established. Per CMS, E/M codes make up 20% of total spending under the physician fee schedule. Part of this initiative aims to reduce the coding and documentation requirements for E/M codes, in turn giving physicians more time to spend with patients. In partnership with The American Medical Society (AMA), CMS worked to revise the rules for evaluation and management coding requirements. These changes were finalized in the 2020 Physician Fee Schedule (PFS) with an effective date of January 1, 2021.
So what exactly was revised? The E/M updates affect codes 99201 through 99215 and include the deletion of code 99201 along with revisions to the code selection for 99202 – 99215. Below is a summary of the revisions to E/M codes:
Elimination of code 99201
Decrease the burden of coding requirements
Decreases the burden of documentation
Decreases the need for audits
Revises the definitions for Medical Decision Making (MDM)
Revises the definition of time spent with the patient to total time including non-face-to-face for E/M services by a physician and other QHP
Requires a history and/or examination when medically< necessary
Offers a clear time ranges for each code for time spent with the patient
Addition of a new 15-minute prolonged service code
Clinicians will choose a code based on MDM or total time
These changes apply to office visits and other outpatient services. It’s noteworthy that these changes represent the first changes to the E/M codes in over 25 years! More importantly, the changes streamline the coding process, reduce clinician burden, and will allow physicians to put the focus back on patient care.
Billing and coding should always be top of mind, but it can be hard to keep up. This is why it’s critical for physicians, clinicians, coders, and billers to completely understand these changes. To help comprehension, the AMA released a checklist identifying ten steps to help the practices prepare for the upcoming changes that can be accessed here. To learn more about the medical coding changes and the summary of revisions, visit the AMA website.
Note: This article is not a comprehensive overview and is NOT intended to provide coding advice, rather it is intended to highlight the new changes in effect and the need for physicians to ensure they have received the proper training for the upcoming changes.
EZClaim Launches EZClaimPay, a new feature in its medical billing software that makes credit card processing painless!
EZClaim, a company with the mission of elevating its clients to stay in front of the ever-changing landscape of medical billing, announced today the launch of its credit card processing feature and service called, EZClaimPay.
EZClaim released the product in August 2020 as a solution to the ever-changing landscape of payment reconciliation. It was cited by customers as a timely response to a ‘pain point’—credit card payment processing—another example of EZClaim’s devotion to their mission.
Dan Loch, VP of Marketing commented that “EZClaim’s goal continues to be making life easier for medical billers at practices and billing firms. EZClaimPay is just one more feature within our mission of living up to that goal.” This feature will help companies get in front of the changes in medical transparency that are coming soon.
EZClaimPay provides for consolidated reconciliation (Payment reports; Chargeback management; and Reconciliation reports) and a single point of contact for support (Hardware; Software; and Payments).
EZClaim has developed a robust payments platform—tightly integrated with their software and support—to make accepting credit cards for payment PAINLESS! EZClaimPay makes software and payments better together.
ABOUT EZCLAIM: EZClaim is a medical billing and scheduling software company that provides best-in-class customer service and support. To learn more, e-mail them at firstname.lastname@example.org or call a representative today at 877.650.0904.
In the wake of the COVID-19 pandemic, Telehealth adoption has exploded, and there are six revenue cycle metrics to track.
Many patients are prohibited or reluctant to venture out for on-site care. The combination of relaxed regulations and expanded payment parity for appointments has made virtual meetings easier and more attractive for providers, who are turning to these technologies to stay engaged with patients—and maintain cashflow. Dr. Robert McLean, a former president of the American College of Physicians, recently said, “this crisis has forced us to change how we deliver health care more in 20 days than we had in 20 years.”
A new industry report predicts that the number of Telehealth visits in the US will surpass one billion by the end of the year, and speculates that nearly half of those visits will be related to COVID-19. At Waystar, we have been closely monitoring claim trends and are seeing this growth firsthand. In fact, the volume of Telehealth claims on the Waystar platform has grown by more than 100 times since mid-March. On two particular days in late April, they accounted for more than 15% of our total daily claim volume. Before COVID-19, they would have accounted for less than one percent!
For many providers, this shift will require new revenue cycle strategies to meet growing patient demand without overwhelming clinicians and administrative teams—or already strained operating budgets. It’s important to remember this is still very much an evolving care delivery model with the opportunity for errors on the part of both payers, providers, and administrative staff. For this reason, revenue cycle professionals should diligently monitor claims to ensure proper adjudication, identify learning opportunities, and uncover areas for operational improvement.
Below, we’ve listed six core Telehealth-related metrics you should regularly track to ensure billing accuracy, maximize payer reimbursement and reduce claim rejections and denials. For more on how to best navigate the evolving telemedicine landscape, check out our resource hub here.
To report on Telehealth-related claims, you’ll first need to identify and isolate claims containing Telehealth procedure codes. See CMS’ Telehealth code list to identify the specific procedure codes and modifiers that apply to your organization.
If your Telehealth claims are being denied or rejected, do you know which specific payers are doing so at the highest rate? Drill down to discover the specific reason codes payers are attaching to rejections and denials so you can better understand payer-specific rules and avoid these oversights in the future. In some cases, you may identify trends that warrant a call to the payer to correct.
Provider Analysis: 3. Telehealth claim volume by provider
Review this claim volume by individual provider. If you notice providers within your organization generating a much lower volume of Telehealth claims than peers, perhaps they could benefit from additional training on Telehealth technology and use cases.
Ensuring Billing Accuracy: 4. Telehealth claim rejections by biller/team 5. Telehealth claim denials by biller/team
Are certain billing personnel or teams producing higher denial or rejection rates than others? Keep a close eye on these trends and remember most of this is new for everyone. If some team members are seeing more rejections or denials than they should, it could be a great opportunity to hold trainings and collaborate on strategies for success.
Maximizing Reimbursement: 6. Telehealth claim volume by procedure code
Which Telehealth codes are you using? Each code reimburses at a different rate, so choosing the wrong ones could leave money on the table. Be sure to read up on CMS’ requirements (check out their fact sheet and code list) to ensure you’re choosing the appropriate code(s) on each Telehealth claim.
You have all the data you need to drive informed decision making and improve financial performance—you just need the right analytics tool in your corner. Our new Waystar Analytics solution offers a pre-built Telehealth dashboard that can help you easily interpret, share all the metrics above, and track these revenue cycle metrics. Click here to learn more about Waystar Analytics and how it can deliver the insights you need during this time of transition.
A group of senators introduced the “Health Care PRICE Transparency Act”in a move to empower patients to lower their healthcare costs.
On a basic level, the Act will require all medical facilities to post payer-negotiated rates for all shoppable services, so the patient can find the most inexpensive way to take care of their medical needs. This legislation will give Americans the chance to see the actual costs of their healthcare visits, which in theory, will increase competition and lower healthcare costs for everyone.
The added transparency of the Act will bring more accountability and competition to the healthcare industry, and gives American’s more control over their healthcare costs. However, if you are a medical practice, a hospital, or a member of the medical billing community, you need to know how you can best respond.
• “What is this procedure going to cost?”: There is going to be mounting pressure on practitioners, medical billers, and hospitals to have answers for the cost of procedures. Jeff Leibach, a director with Guidehouse’s healthcare strategic solutions team, says that “regardless of the legal fate of the final rule, hospitals need to be prepared for more price transparency in the future.” So, to get in front of this—and help you compete against your competitors—you should be prepared with both what it will cost for individual services and procedures, as well as, a ‘value statement’ on why it will cost what you are charging.
• Prepare to Comply or Cover the Costs: As it stands now, the legislation is moving towards technology assisting with the billing transparency. This will aid the patients to better understand the cost of services. This is a ‘clarion call’ for you to begin preparing for this reality or you will struggle with being fined and potentially publicly shamed in publications for being offenders. We recommend starting to comply NOW before the deadline ‘sneaks up’ on you.
• Use It To Improve: Currently, healthcare practices are, in many cases, already working at capacity. The added effort of defining cost and selling procedures are enough to make some healthcare facilities put this off until it is too late. Yet, while many may be considering accepting the fines and fees associated with non-compliance, we advise using this as an opportunity to improve—to better establish your medical practice’s services, and promote your ability to be proactive to change. Getting ahead of the coming ‘wave’ of consumer expectations of healthcare will be a benefit.
• Seek Out Vendors That Can Assist: The changes that are coming for individual practices and healthcare providers can be overwhelming, and potentially it might just be more than what an IT team or private practice can handle. Forward-thinking billing departments should be investing in software vendors that can help fill that gap. EZClaim is a medical billing software company that partners with Trizetto to provide a tool called, Patient Responsibility Estimation(PRE). This tool assists in clarifying costs to consumers by providing a cheap and fast way for them to pay for out-of-pocket costs. [ Click here to learn more about how EZClaim can help you ].
It is clear that the expectations of consumers are changing, and the wave of medical transparency is on its way. Accepting it, preparing for it, and using vendor software to help overcome it, can be the difference of your practice avoiding fines and fees. For those forward-thinking and proactive practices who want to learn about how EZClaim can help, e-mail one of their sales representatives, go to their website for more details, or download a FREE 30-day trial today!
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