Apr 12, 2022 | Partner, TriZetto Provider Solutions
From the onset of the pandemic, burnout has been one of the biggest challenges facing healthcare workers. Beyond the physical aspect of being overworked and risking one’s own health to help those in need, there is also the toll the jobs takes on mental health. And burnout doesn’t only affect front-line workers. While nurses and doctors may face the brunt of pandemic-related woes, administrative burdens also impacts office staff and C-suite executives. It truly is a top-to-bottom issue.
This burnout, coupled with other issues like employee vaccine mandates and patients behaving badly, has no doubt taken its toll on healthcare workers. And the result? Resignations. Just as The Great Resignation rocked Corporate America, the healthcare industry has also felt the effects. It’s such an issue that industry CEOs ranked personnel shortages as the number one challenge they face, according to new survey results from the American College of Healthcare Executives. And the recent numbers do not lie. Hospitals lost 5,100 jobs in December 2021, according to the U.S. Bureau of Labor Statistics, with nursing and residential care facilities losing 6,100 jobs the same month, respectively. And it’s not just front-line workers that are resigning. The Medical Group Management Association (MGMA) claims 88 percent of medical practices have had difficulties recruiting front office staff.
Much of the operational tasks handled by front office employees are critical to the functioning of a practice – coding, scheduling, bill processing – need to be done regardless of staff limitations. Administrative burnout is real, and when there is an overall decrease in staff, the remaining employees are often left to pick up the slack.
Increasing costs and budgets
According to Mercer’s 2021 External Healthcare Labor Market Analysis, which examined predictive healthcare labor statistics over the next 10 years across all 50 states, labor shortages should be expected as the U.S works through the COVID-19 pandemic. With the issue of resignations and burnout not going away any time soon, leaders need to find ways to adjust. If healthcare employers want to gain and retain workers, money talks. While offering higher-than-usual salaries and additions like sign-on bonuses may not have been originally in the budget, it may be the right route to circumvent staffing issues. And as inflation and the overall cost of living rises, employers are finding that more money than usual may need to be allotted for payment increases too. A MGMA Stat poll found that fifty percent of healthcare practices budgeted more than usual for workers’ cost-of-living increases for 2022. With costs anticipated to rise, practices need to get ahead of their budgetary planning to put themselves in the best position, staffing-wise, to succeed in years to come.
Staffing the Practice of the Future
One way that organizations are trying to navigate staffing issues is though flexibility. A 2022 MGMA poll found that 59% of medical group practices shifted workers to permanent and/or hybrid work in 2021. Said workers included roles like coders, call center representatives and administrative positions. One year after the onset of the pandemic, an MGMA Stat poll showed that one in five practices said that more than 25 percent of their workforce was remote at least half the time. One of the nation’s largest health systems, the Cleveland Clinic, currently has nearly 8,000 administrative employees in at least a partially remote work model. Leadership is seeing the advantages of remote work, including reduced overhead costs, more satisfied employees and the ability to cast a wider recruiting net that is no longer limited to a single geographic region.
Over the last two years or so, organizations witnessed the positive outcome of remote work and decided not to switch back to traditional models. Another, more proactive way to alleviate administrative burnout is to get things right the first time. The key to this is having the right technology in place, like claims management and eligibility verifications, that can increase automation and create the most efficient workflows. Business processing services, including end-to-end billing and credentialing services can alleviate manual work and automate processes. Outsourcing is another logical path to take when there is just not enough hands in-house to manage day-to-day tasks.
With remote work and outsourcing now seen as viable options, organizations must adjust to keep with the times. If the C-Suite wants to retain and recruit talent, finding solutions that are satisfactory for the employee and employer should be a top concern for 2022 and beyond. Overall, organizations need to meet the needs of their employees. These needs may be vast and varied, but most executives would agree that it centers on flexibility, connectivity and technology.
Organizations looking for assistance implementing automation and RCM resources can learn more about ways TriZetto Provider Solutions can help by visiting trizettoprovider.com/ezclaim.
Feb 10, 2022 | Partner, TriZetto Provider Solutions
While the No Surprises Act aims to address many issues involved in the patient price transparency process, a lot of attention will be put on out-of-networks charges. Many of the provisions will address how patients will be relieved of surprise medical bills from services that were rendered by providers outside of their insurance networks, and providers are wanting to know how to prepare for potential changes in their revenue. We detail how CMS has planned to address out-of-network payment disputes for emergency situations, as well as situations when services were non-emergent.
Emergency Out-of-Network Services
Providers will begin to see differences in reimbursements for emergency out-of-network claims. These will be paid using a ‘Qualified Payment Amount’. Payers are instructed to use different methods to determine the payment amounts, which will vary by the location of the service.
Dispute Resolution
Providers will need to be prepared to review these claims to see that they were paid appropriately or if there is a need to dispute the claim. If a dispute is in order, CMS provides a portal to initiate a dispute. Dispute resolution follows a strict timeline that goes as follows:
- Submit Claim
- After claim submission the health plan has up to 30 days to pay or deny
- Negotiate Payment
- Next, payers and providers have 30 days of claim payment or denial to negotiate
- Initiate Dispute
- Providers then have within 4 days of end of negotiations to initiate a dispute using the CMS Portal
- Select Arbitrator
- If no agreement come from the negotiations, one will be selected by CMS within 3 days
- Submit Dispute
- Within 10 days of arbitrator selection, provider and payers submit documentation and offer for reimbursement
- Arbitrator Decision
- The arbitrator then decides which offer to be paid within 30 days of the dispute
- Final Payment
- And final payment will be made within 30 days of the arbitrator decision
Non-Emergency Out-of-Network Services
The No Surprises Act prescribes that out-of-network patients will receive good faith estimates prior to receiving services at medical facilities. The act covers self-pay and uninsured patients, but may also include patients whose health plan does not cover the services to be provided, as well as patients who have benefits but are opting not to use them. Patients who receive a bill for services that differs from the estimate by more than $400 will have up to 120 days from receiving the bill to dispute the charges. Additional rulemaking will be forthcoming to define how provider and payer systems should interact to provide cost information for the estimate.
Keep abreast with updated regulations and the key points of the No Surprises Act (NSA) that could impact your revenue cycle by visiting TriZetto Provider Solutions’ designated landing page. Subscribe to NSA news updates and explore solutions that equip you to have informed conversations about financial responsibility and eligibility.
ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
Dec 30, 2021 | Partner, TriZetto Provider Solutions
Are You Getting the Most Out of Your Credentialing?
Enrollment status can greatly affect the dollar amount payers reimburse, and some specialists are opting to go out of network. We weigh the pros and cons of this trend to explain why it may make sense for select providers.
Did you know that reimbursement is directly tied to credentialing? It’s all in the details, and enrollment status can greatly affect the amount payers reimburse. When enrolling as an in-network provider, payers and providers decide on an agreed-upon rate. However, a physician can decide to forgo a traditional contract with a payer and instead choose to be labeled as “out of network”. Of course, they will still be listed as a provider, albeit without the stated reimbursement rates and payment security that comes with having a contract in place.
If you are wondering why this option is appealing to some physicians, just look at common treatments the average healthcare consumer may be familiar with. Every year, most adults and children visit their local eye specialist for an annual exam. An optometrist performing a routine eye exam will most likely receive optimal reimbursement. This service is covered by insurance in the majority of cases and the reimbursement will be within a standard range. However, if this same patient is then referred to an ophthalmologist for advanced cataract surgery, for example, the odds of insurance covering this procedure are less likely. From the standpoint of the ophthalmologist, his credentialing specifics may not matter too much, since he will be paid regardless and the patient is most likely assuming that they will have a large out-of-pocket cost. When all is said and done, the ophthalmologist is set up to take home more than if he was listed as an in-network option. Looking at it through the eyes of the surgeon, it would not make sense financially to be credentialing with payers the traditional way.
The benefit of being in-network boils down to the contracts that determine what providers will be paid. When a provider works with a payer, an agreed-upon rate is determined. If paperwork is filled out correctly and claims are submitted on time, there will not be too many surprises when the time comes to be reimbursed. A provider will know what to expect from a particular service. This process works best for providers that like the security of having a contract in place. However, these contacts with insurance companies often result in providers being paid less than fair market value. The truth of the matter is that fair market value may often be more than payers are willing to pay.
It’s not uncommon for family doctors, or eye care professionals that deliver routine exams like the example mentioned above, to work in-network because the margins are small. For highly specialized services, often considered elective and not covered by insurance, the potential for large reimbursement grows significantly. For instance, let’s say a plastic surgeon performs surgery in their own surgical suite. The procedure may cost $14,000. Through payer reimbursement as an in-network provider, the surgeon receives $4,000. However, if the surgeon is considered out-of-network, they have the ability to negotiate rates, meaning much more could potentially be earned. From the patient’s standpoint, it’s not uncommon for a patient to shop around and expect to use an out-of-network provider anyway for these types of highly specialized services.
When it comes to gaining credentials, an out-of-network provider will not have to go the traditional credentialing route. This question arises: Is it smarter for medical professionals to perform their services as in-network or out-of-network providers? The truth is, a lot of doctors do not actually realize they have the ability to negotiate. It all comes down to how they want to pay, and the power lies with the provider.
Credentialing is complicated, and it helps to have the right partner in place to navigate the path to credentials. TriZetto Provider Solutions (TPS) has experienced credentialing experts in place that can help with every aspect of the process. Visit our TPS partner page to learn more and request a demo.
ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
Nov 18, 2021 | Partner, TriZetto Provider Solutions
With two more states recently joining the list of locations that allow Full Practice Authority, many nurse practitioners are exploring the option of operating independently. As the need for qualified healthcare professionals continues to grow and the ability for NPs to practice independently continues to increase, quickly gaining credentials and navigating compliance challenges becomes more and more important.
Recently, Massachusetts and Delaware became the latest states to enact Full Practice Authority (FPA) for nurse practitioners (NPs), bringing the total number of states to 24. With this new inclusion, nearly half of U.S. states now allow nurse practitioners to operate on their own. Essentially, this means that registered nurses can practice independently from physicians, allowing for more autonomy in their careers and the care they provide.
So why this is significant? This means that registered nurses can practice independently from physicians, allowing for more autonomy in their careers and the care they provide. Nurses are no longer “tied” to physicians, so to speak.
These new laws cannot come at a better time. We know that the amount of practicing medical doctors has dwindled in recent years, due to the pandemic and many providers leaving the field. This has led to a short supply of physicians in the U.S., which has only 2.6 practicing physicians per 1,000 people, compared to 4.3 in Sweden and 3.2 in France. This decrease is driving unprecedented demand for nurse practitioners (NPs), with an expected increase of 52% through 2029.
Traditionally, state practice and licensure laws required NPs to have a career-long collaborating or supervising physician to provide patient care. However, with more and more states allowing Full Practice Authority, now nearly half of U.S. states now allow nurse practitioners to operate on their own. But in order for NPs to move forward with independent practice, credentialing is essential. How can nurse practitioners looking to establish their own practices quickly gain credentials and painlessly navigate the challenges of compliance?
Operating independently means nurses need to establish credentials as a standalone provider to be eligible for in-network status to receive physician-level reimbursements. These tasks, and complying with the Council for Affordable Quality Healthcare’s (CAQH) requirements, can be taxing and time-consuming, even for the most seasoned professional. Creating a new CAQH application is highly manual, and the required quarterly updates for re-attestation can be onerous. Extensive credentials including education, residency, internships, and peer references are also required, which require time to gather information and resources. It’s not an exaggeration to say that many hours must be spent uploading copies of licensing information, board certifications, DEA registration, and insurance certificates.
NPs looking to leave their current situation may need help navigating credentialing challenges. Partnering with a third-party provider to help manage credentialing lightens the load and allows nurses to focus on patient care. TriZetto Provider Solutions (TPS) offers an end-to-end credentialing service that ensures continuous payer follow-up and insight into enrollment status.
Discover the most painless way to gain credentials. Visit our TPS partner page to get started.
ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
Oct 14, 2021 | Partner, TriZetto Provider Solutions
New No Surprise Act Tackles Unexpected Medical Bills
Two-thirds of bankruptcies filed in the United States are a result of medical expenses. It’s an alarming statistic, but probably not surprising. It’s no secret that many people have trouble paying out-of-pocket medical costs, so much so that a recent survey from The Commonwealth Fund found that 72 million Americans have some sort of trouble with medical debt.
It’s a common problem, but why? Let’s say a person visits a hospital, perhaps an emergency room, and receives a myriad of services. Maybe they arrived via ambulance or required treatment from an anesthesiologist. Although they may inquire about an estimate at the time of service or have an idea of their coverage, the exact financial responsibility is often a mystery. But what’s a person to do? They need medical assistance, and they need it at that moment. Then a surprise arrives in the mail in the form of an outrageously high medical bill. It’s something many of us have likely experienced.
What’s the cause of such an expense? Often the charge stems from using an out-of-network provider. Basically, this means that the hospital may have been in-network, but the physicians were not. Additionally, patients are often confused about medical coverage. Even with a good understanding of their benefits, situations may arise that are out of their control, and there may be unintended outcomes. Patients may (falsely) believe that all services rendered will be considered in-network when they go to an in-network facility. However, this isn’t always the case. In some instances, even though their physician is in-network, patients referred to specialists (such as a pathologist or radiologist) may discover the ancillary services were out of network. It is only after the patient receives a bill that they discover the issue. In the case of an emergency visit, patients don’t have the luxury of researching for in-network hospitals and typically go to the nearest hospitals. Patients may also be taken to out-of-network hospitals by ambulance. Researchers estimate that 1 in 6 emergency room visits and inpatient stays involve care from at least one out-of-network provider. The cost of out-of-network visits can have devastating financial consequences for the patient.
A 2019 study by the Government Accountability Office (GAO) found that the cost for air ambulance services clocked in at approximately $40,000. A large portion of this cost (over 70 percent) often fell out-of-network, meaning that the balance usually was placed on the consumer. When such a service is needed, it’s understandable to not have the option to “shop around” for a cheaper, in-network alternative.
Thankfully, help is on the way. Leaders and policymakers at the federal level have taken steps to tackle the issue. On July 1, 2021, the Biden Administration announced a new rule aimed at protecting consumers from surprise medical bills. In conjunction with the Department of Health and Human Services (HHS), together with the Departments of Labor and Treasury and the Office of Personnel Management, debuted “Requirements Related to Surprise Billing; Part I.”
This announcement, the first in a series, will go into effect on January 1, 2022, and protect patients from those all-too-common surprise medical bills. It’s an important step forward in protecting patients.
“No patient should forgo care for fear of surprise billing,” stated HHS Secretary Xavier Becerra. “With this rule, Americans will get the assurance of no surprises.”
Let’s dive into the new regulation. Among other provisions, the rule:
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- Protects patients from surprise billing in emergency services. These provisions will safeguard patients in emergency care situations from unknowingly accepting out-of-network care and incurring unexpected expenses.
- Limits out-of-network cost-sharing. Patient cost-sharing for emergency and non-emergency services, such as a deductible, cannot be higher than if provided by an in-network provider. Simply put, co-insurance or deductibles must be based on in-network rates.
- Bans out-of-network charges for ancillary care. Previously, out-of-network providers like anesthesiologists could have been assigned, even though the facility or physician was in-network.
- Requires that providers and facilities provide patients with accurate cost information and advance notice of any out-of-network charges for non-emergency services. A consumer notice must explain that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
- Allows providers and insurers access to a dispute resolution process should reimbursement issues arise around reimbursement.
With the increase in high deductible health plans and increased out-of-pocket costs, finances are top of mind. From the consumer’s standpoint, gaining healthcare services will be less stressful. On the simplest level, this ruling will hopefully eliminate those hefty surprise bills, which can only be seen as a positive. Moving forward, patients can rest assured that they will be more aware of expenses and will avoid out-of-network charges for emergency care.
So can consumers finally say goodbye to surprise medical bills? Hopefully, they become a thing of the past. And how will this bill affect the future of the industry? Advocates are hoping these regulations and newfound transparency will eventually lower costs, for one. More importantly, it shines a light on the need to improve the overall patient experience. It’s a step in the right direction and has the potential to improve healthcare policies going forward for years to come.
For more information on solutions that equip you to have informed conversations about financial responsibility and eligibility, contact a TriZetto Provider Solutions representative today.
ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
Sep 29, 2021 | Partner, TriZetto Provider Solutions
With healthcare costs on the rise and an increasing segment of uninsured consumers, the patient payment landscape is changing rapidly. How can medical offices evolve and optimize collections while keeping patient satisfaction high? Thankfully advancing technologies are making it easy to simplify collection processes to increase revenue.
1) Communicate responsibility
How many times have you purchased a good or service without knowing the cost beforehand? Probably not many. Healthcare should not be any different. By providing cost expectations, care providers can give patients the opportunity to not only understand their fiscal responsibility but to also take a proactive, involved approach. Communication allows patients to determine if the value of the service they are receiving is worth the cost. When finances and choices are transparent, patient satisfaction rises.
2) Collect upfront
It’s said that medical providers collect only 25 percent, on average, of available co-pays and deductibles at the time of service. If the patient departs after the initial visit without making a payment, the likelihood of receiving the co-pay drops significantly. Consumers are used to paying for a product at service at the time of use, so why should medical care be different? Capitalize on patients that are willing to pay at the time of service by collecting upfront. Processing payment during the appointment is a step toward helping the patient to be invested in their care, which increases the chance of gaining future payments.
3) Empower patients
We know that patients are taking a more active role in their care and like to be in control of costs. Knowledge is power, and giving patients the information and tools needed is critical to empowering patients to pay. An effective strategy engages the patient early to learn their payment and communication preferences, then proving the proper options.
4) Build awareness
When adding payment options or considering changes to your payment workflow, increasing awareness is key. Be sure to engage your staff and provide the most accurate information on your website and within advertising tools (such as posters in the waiting room). If time and budget allow, conduct a survey to gain patient feedback. A small sampling of users will give insight into the likelihood that patients will adopt new tools and practices. It’s critical to explain the value in an informative, yet simple to understand the way that will resonate with your audience.
Thinking your practice may not have the staff or means to optimize payment processes? Consider tools from TriZetto Provider Solutions that can enable patients to conveniently pay by utilizing a variety of methods, including easy-to-understand statements. Learn how our partnership can help you streamline your workflow, improve efficiencies, and get paid faster.
ABOUT EZCLAIM:
As a medical billing expert, EZClaim can help the medical practice improve its revenues since it is a medical billing and scheduling software company. EZClaim provides a best-in-class product, with correspondingly exceptional service and support. Combined, EZClaim helps improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.
