A summary of the most significant payer compliance changes and market updates Advantum Health shared this past year.

Multiple public and private payers implemented changes to their rules and regulations in the last 12 months. 

Here’s a summary of the most significant payer compliance changes and other RCM updates Advantum Health shared during that time period:

1. Prior Authorizations Under Fire

Anyone who has worked a day in the revenue cycle industry knows that the prior authorization process is painful, especially for healthcare providers.

Now, with public support fueling federal and state legislation, it seems like positive change is on the horizon. 

Last month, CMS finalized a new prior authorization rule and Tammy Taylor, our CEO of Advantum Health, shared her thoughts on how it will streamline and enhance the billing process, promising significant benefits for clients. 

In addition, most US states are considering laws to reduce the complexity of payers’ prior authorizations that waste time and delay patient care. Nearly 90 prior authorization reform bills have been considered in 30 state legislatures, with more than a dozen still under consideration for possible passage.


2. E/M Coding Changes Every Provider Should Know

Prior authorizations isn’t the only administrative burden leading to physician burnout. In addition to initiating prior authorization reform, the AMA also revised the Evaluation and Management (E/M) clinical documentation. 

Advantum Health summarized five key takeaways from the 2023 E/M CMS Coding changes: 

  • 2021 E/M office visit code revisions applied to other E/M families of services.
  • Emergency Department Providers (still) cannot use time as a code selection factor.
  • Providers will no longer use separate Observation and Inpatient CPT codes. 
  • Emergency Departments can select a CPT code when a physician or QHP may not be needed for treatment.
  • Providers can include both face-to-face and non-patient-facing work in their Inpatient Services total times.

One thing is clear: it’s important to make things easier for doctors’ offices. From prior authorization reform to common sense E/M coding, it’s important to simplify the administrative burdens in physician practices. 


3. Telehealth Billing is Here To Stay

Even though telehealth billing volumes have dropped from peak COVID-19 pandemic levels, experts predict telehealth will continue to expand its reach and capabilities. 

Over time, telehealth claims will make up a larger and larger portion of the total number of claims that hospitals process. 

Advantum Health discussed telehealth market trends and critical billing implications from the Consolidated Appropriations Act of 2023 extending many of the PHE flexibilities through December 31, 2024, and making some of them permanent. 


4. FY2024 IPPS and LTCH PPS Proposed Rule

Advantum Health summarized CMS’ proposed rule rate adjustments and potential implications. 

The CMS predicted a $3.3B increase in hospital payments with the proposed operating and capital IPPS rate adjustments. 

However, CMS also estimated a reduction of $575M in hospital payments due to the expiration of new technology add-on payments ($460M) and decreased uncompensated care and disproportionate share hospital (DSH) reimbursements ($115M).


5. Advantum Ai Overlay Platform: An Origin Story

When Advantum’s revenue cycle team needed a robust data management tool to streamline their operations and enable greater scale for their line of business, they leveraged their deep revenue cycle expertise and built the Advantum Ai application

This article describes what the Advantum Ai overlay platform is, how it works, and why it changes the game for Advantum Health.

What started as an internal denial improvement project transformed into a comprehensive RCM software suite ready to integrate with any client’s PMS.

6. Outsourcing RCM Enables Growth 

If healthcare organizations seek to thrive in today’s marketplace, they must adapt and grow, in other words: scale their business operations. ​​Effectively scaling an organization requires a well-thought-out and strategic approach.

Outsourcing Revenue Cycle Management (RCM) can be highly advantageous in enabling an organization’s efficient growth and scalability. By outsourcing RCM operations, healthcare organizations gain access to specialized expertise, cost-effectiveness, scalability, reduced administrative burden, and advanced technology. 

This allows healthcare providers to focus on their core competencies while benefiting from efficient revenue cycle management.


7. Demystifying Revenue Cycle Management

Want to better understand what it means to work in revenue cycle management? Or, if you work in RCM, do you need help explaining your job responsibilities to others outside the industry?

Then, this article is for you. Advantum Health created a jargon-free overview of the ins and outs of RCM for healthcare executives, administrators, and practitioners.

This article breaks down the healthcare revenue cycle and explainsexplain its key concepts in a relatable yet informative manner.

What’s Next…

Stay tuned for more healthcare revenue cycle industry updates in our new Revenue Cycle Round Up series where we share the latest trends in revenue cycle payer compliance, IT, and operations.