Tammy Taylor, the CEO of Advantum Health, shares her perspective on the implications of the new rule, finalized on Wednesday, and what it means for the revenue cycle marketplace.
By: Tammy Taylor
In the past few days, those of us working in revenue cycle management have analyzed the intricacies of the finalized CMS rule and its implications for individuals, organizations, and clients.
You may be wondering…
How will this new CMS rule impact our daily billing operations, cash flow, and budget?
Me too.
Overall, this new legislation benefits providers, patients, and third-party billing companies.
Although it doesn’t address all prior authorization issues and only applies to CMS payers (excluding commercial health plans), it represents a long-awaited step in the right direction.
Here are my initial thoughts:
The prior authorization process should be more efficient.
Payer Decision Timelines
CMS established a time frame for payers to communicate prior authorization decisions to healthcare providers.
- Urgent: 72 hours
- Standard: 7 calendar days
Payers will need to supply denial reasons.
If a payer denies a prior authorization request, the denial response must include a specific reason for the denial.
These new communication requirements for payers should make the prior authorization process more predictable and efficient.
This would enable third-party billing companies to manage their team’s workflows and client expectations effectively.
The administrative burden of prior authorizations should decrease.
By streamlining the prior authorization process, the new rule aims to reduce the administrative load suffered by healthcare providers.
Implementing this solution has the potential to greatly benefit clients of third-party billing companies. It can lead to smoother billing processes, resulting in fewer denied claims due to authorization issues. This means that clients can expect a more seamless experience, reduced payment delays, and improved financial outcomes.
There will be enhanced data access and exchange.
With the requirement for expanded patient access APIs and the introduction of provider access APIs, third-party billing companies will have greater access to claims, encounter, clinical, and prior authorization data.
This enhanced data exchange can improve billing accuracy and reduce the time spent on resolving discrepancies.
There will be new technology standards and requirements for providers and third-party vendors.
Technology Standards
The new rule mandates providers and payers to implement Health Level 7 Fast Healthcare Interoperability Resources (FHIR) standard application programming interfaces (APIs) to support electronic prior authorization.
Many healthcare practices do not have the required IT infrastructure to support electronic prior authorizations, and they’ll need help from their technology partners.
This presents an opportunity for third-party billing companies to invest in technology upgrades and training to align with these new standards. By doing so, they can enhance their capabilities, streamline operations, and provide clients with more efficient and reliable billing services.
Compliance Requirements
Third-party billing companies must ensure that they comply with the new rules, including adherence to the timelines for decision-making on prior authorizations.
Ensuring compliance is crucial for third-party billing companies as it helps avoid penalties and maintains positive relationships with healthcare providers and payers. Clients can rely on our commitment to compliance to safeguard their interests and maintain smooth interactions within the healthcare ecosystem.
Conclusion
The upcoming rule holds the promise of significantly streamlining and enhancing the billing process for our clients. While it does entail investments in technology upgrades and a strong commitment to compliance and operational efficiency, the benefits are substantial.
With quicker turnaround times for prior authorization and increased transparency, our clients can anticipate a much more efficient revenue cycle. This may translate into faster payments and a reduction in billing backlogs, ultimately bolstering their financial health.
However, we understand the importance of adaptability. As these changes unfold, we are committed to continuously monitoring their impact on our operations and adjusting our practices to best serve our clients. We’ll stay vigilant about any further regulatory changes or updates to technology standards to ensure our clients remain at the forefront of industry best practices.
The great news is that we will handle all the necessary changes and adjustments on our end. Our clients can rest assured that we are committed to ensuring a seamless transition, which will ultimately lead to a wonderful experience for them.