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The Impacts of Regulations on the Revenue Cycle [PODCAST]

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In this episode, Rodney Adams, Vice President of Research and Reimbursement for the Tennessee Hospital Association, discusses the impacts of regulations on the revenue cycle.

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Highlights of this episode include:

  • Some of the ways that government actions can impact revenue cycle operations
  • How legislation recently impacted revenue cycle operations
  • How the government rules and regulations recently impacted revenue cycle operations
  • How revenue cycle leaders stay informed about potential legislative and rule impacts
  • How revenue cycle leaders potentially impact pending legislation or proposed rules

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Rodney Adams, Vice President of Research and Reimbursement for the Tennessee Hospital Association. In this role, he works with hospitals across Tennessee in the areas of managed care, revenue cycle, case management, and utilization review and compliance. Prior to his current role, he was the Associate Administrator of Finance for Williamson Medical Center in Franklin, Tennessee, where he oversaw patient access, health information management, coding, case management, patient financial services, and managed care. He was also with Maury Regional Health System for almost 12 years, holding various roles during his tenure there. Rodney is a past president of the HFMA Tennessee Chapter and has obtained both the CRCR and the CHFP certifications from HFMA. He holds a bachelor’s degree in business administration from Moore National University and completed his graduate studies at Vanderbilt University’s Owen School of Management, where he obtained his master’s in the management of healthcare. In this episode, we’re discussing the impacts of regulations on the revenue cycle. Welcome back and thank you for joining us today, Rodney.

Rodney Adams: Hi, Kelly. Great to be back with you. Thanks for having me.

Kelly: Well, yeah, we love to have you back. And so let’s go ahead and jump in today. So, what are some of the ways that government actions can impact revenue cycle operations?

Rodney: Yeah. Kelly, there are a lot of ways that the government’s impacting revenue cycle operations these days. I think two primary ways are through legislation. And that can happen at the state level as well as at the federal level. And then there are a number of rulemaking processes that are ongoing from various departments that can really, even outside of the legislative process, have significant impacts on revenue cycle operations. And spending 17 years on the provider side and being in revenue cycle for the great majority of those years directly, I never realized, I think, the impacts that the government– I mean, obviously, you have updated rules annually, like IPPS, OPPS that come out from CMS. But just the sheer volume of rules and regulations and laws– and I think, granted, there are probably more of those now over the past few years than there were early in my career. But I don’t think I really gave enough credit to the amount of impact that was happening at that level until I joined THA, now two and a half or a little more years ago, and really started to be able to be more familiar with the processes that were going on. And now it’s just baffling. I mean, the volume of these rules, the significance of these rules, and the fines and penalties and so on that are associated with not following rules, regulations, and laws is significant.

So, it’s definitely something that I think revenue cycle leaders should be keeping a very close eye on.

Kelly: Sounds like it. That sounds like something they should really be paying attention to. So first, let’s tackle legislation. How has legislation recently impacted revenue cycle operations?

Rodney: Yeah. I mean, there have been a couple of federal bills that have been introduced, like pricing transparency and the No Surprises Act, just over the last, say, three to four years that have had some pretty significant impacts. And everyone’s probably familiar with those. I mean, the pricing transparency, and then subsequent rulemaking that’s really changed– and we’ll talk about rulemaking, I’m sure, as well, but really continues to change the direction of what’s happening with pricing transparency. And then you’ve got the No Surprises Act, which kind of had this bipartisan support for surprise billing. And it has completely upended revenue cycle processes from the requirement to provide good faith estimates to many scheduled patients and the specific requirements now that exist for out-of-network providers. I think revenue cycle staff have been forced to learn more about coding, billing, contracts, and reimbursement than they ever really had to know before to be able to answer patient questions as patients are navigating through the system. And then, not to mention the impacts of the independent dispute resolution or IDR processes that have come out of that. And now we’re, I think, on TMA4. So, there have been four rulings where the Texas Medical Association has filed suit against CMS and the rules that are required in this IDR process, and it’s this increased complexity that has been given on these out-of-network claims where now you’ve got qualifying payment amounts.

And so, we’ve got all these new acronyms, right? QPAs, qualifying payment amounts, GFEs, good faith estimates, IDRs, the independent dispute resolution process, and the IDREs, the independent dispute resolution entities that oversee this process, and the delays that are associated with those, and the complexity of the entire IDR process. I mean, literally, there are days where you must file this complaint. You must work with the payer for so many days. You must then follow up. And just the level of detail that is required to go through that is just enormous and has created quite the administrative burden. And then you have providers, at least in my experience, who are saying, “This process is so complicated. We’re not going to pursue trying to fight these underpays, or it’s not cost-effective for us to fight these.” And so, providers are winning, I think the last statistic I saw, about 80% of those IDRs, the complaints that they’re submitting. The problem is, I think there are a lot more complaints that aren’t being submitted. And so that’s a fair amount of detail, but all of this was done in legislation and subsequent rulemaking around these legislative efforts. And then I think at the state level, everyone probably has a number of state-level changes that have created revenue cycle impacts. In Tennessee, just last year, there was a bill passed around prior authorizations.

It closely mirrors what the CMS has now finalized as their prior authorization rules. Those were not finalized when this bill was passed in 2023. They were only proposed at that point, and then now have been finalized. But there will be impacts to revenue cycle processes from that legislation just at the state level. And there are a number of other states who have passed bills around white bagging processes or prior authorizations or gold carding or requiring providers– I know even out West, there are some states who are either seeking or have passed legislation around provider-based clinic billing and limiting what providers can do there. And I would say, I guess, just to kind of wrap this up, it’s incredibly difficult to keep up with what’s going on in your state. But it’s also important to not only keep up with what’s going on in your state and at the federal level from a legislative perspective and what’s going through these processes, but also to understand what’s in other states. Because some of those are viewed by your state legislatures as best practices, or there are groups that are pushing specific agendas. And we tend to see many of these things kind of sweep across the country. They start, and then they kind of grow and expand out. And so, I think it’s important to know what you’re up against and what you’re dealing with and what some of your peers are dealing with in other states too.

Kelly: Yeah, I was just thinking this is a lot to keep up with. So yeah, that’s very challenging.

Rodney: And we can talk about some ways that people can stay informed too. So, we’ll cover that. Let’s go ahead with your next question, and then we can kind of circle back.

Kelly: That sounds like a great idea. So, let’s talk about government rules and regulations next. So how have government rules and regulations recently impacted revenue cycle operations?

Rodney: Yeah, for sure. I just mentioned the rules and regulations associated with prior authorization. And so those haven’t become final yet. Many of the provisions in that rule take effect January 2026 or January 2027. So, there’s some lead time of close to two to three years that hospitals have. So, I would encourage people before those impacts arrive, there is some planning that’s going to be required to meet those obligations from the hospital side. There are meaningful use impacts potential by 2027, if you’re unable to meet those requirements. But there are also going to be some really good things for patients in there, as well as providers, that are going to shorten the timeframes that Medicare Advantage, CHIP, Medicaid, and exchange plans have to respond to prior authorization requests. And so, I think there’s some really good things there. Probably the rule with the most impact on revenue cycle and really even case management operations at this point was the final rule for contract year 2024 was finalized in April of 2023. And this was around Medicare Advantage. And there’s a lot of impacts there to midnight rules. So, a lot of changes in patient status. And that’s going to have some revenue cycle impacts. There’s going to be the need to track denials, to track and understand how payers are responding to those rules, not just with case management and what’s getting approved, but what’s actually getting through on the claim.

And then the need for providers to really understand, are there changes in behavior in other places? Because just because an inpatient was approved doesn’t mean that inpatient will be paid, and it doesn’t mean that there won’t be other potential tactics to change that reimbursement. And so, there are things, like not separately payable procedures that happen on inpatient claims, and a lot of our revenue cycle folks are going to be very familiar with that. That’s one where I would say you should be keeping a close eye on these new MA rules and what you’re seeing as a result of those rules that were finalized– 1/1/24 is when they took effect. So, I mean, we’re a few months in now to that process. So, it’s probably too early to call things a trend. I’ve always heard a few data points are only a trend if it’s what you’re looking for, so. But I would encourage folks to keep an eye on that. We talked a little bit about the rulemaking also that’s come out of pricing transparency. And that’s been significant. There have been multiple changes to the pricing transparency requirements, even more changes that took effect 1/1/24 with more changes coming probably shortly after– soon from now, on July 1st, there are even more changes. And so everyone’s probably aware of what’s happening with those. But like I said earlier, there are more and more of these things that are coming out now. And just trying to stay on top of it is a challenge, I think.

Kelly: Definitely. It does seem like it can be overwhelming. And I know we kind of talked about this earlier, and you just mentioned it. So how can revenue cycle leaders stay informed about potential legislative or rule impacts? It seems like there’s just so much happening.

Rodney: There is a lot happening, and there are several ways to stay informed about it. Some are much more efficient than others. I have found that reading the federal register is not the most desirable way to stay informed about what’s going on at the federal level. Most of these rules, when they get released, are 500 to 1,500 pages in the federal register. And I know, in my role now, that’s a stretch to be able to do it. And in my roles previously, to think that I was going to read 500 to 1,500 pages of the federal register, which is not the most riveting read that you will have for the month, was just impossible. I mean, when you’re managing revenue cycle operations, managing teams and departments and new projects, that is the least effective way, unless you’re just having trouble sleeping and say, “I want to read the federal register.”

Kelly: Right.

Rodney: Very few people get much enjoyment out of reading that. There are some, and I appreciate them so much. I think the best ways, though, to stay informed about potential legislative and rule impacts, and it’s through your State Hospital Association, through the AHA, through the Federation of American Hospitals that are at the national level. The AHA and FAH, both at the national level, do a really good job of sharing summaries of upcoming rules, of upcoming or pending legislation. If your organization has a government affairs people, they are probably getting a lot of emails and input about these things. And I think it’s important to form a kind of partnership with those government affairs people within your organizations, especially if you’re part of a fairly large or mid-size to large organization, leaning on them to say, “As bills or regulations are released, and especially when bills start to seem like they’re getting some traction, sharing what–” Ask them to share with you what some of those provisions are so you can understand, are there going to be potential revenue cycle impacts, are there going to be potential patient impacts, and providing them with some feedback about what that is. Also, your state hospital associations. Part of my role at THA is to work with our members, particularly on payer-related issues and items that are coming up.

And so we tend to stay on top of these things and can share summaries and really seek feedback from revenue cycle leaders around, “What are your thoughts? What would this mean? And could you implement this? Is this a reasonable something to implement? Or is this something that you would have to have new systems and software and technology to be able to do?” Because remember, people who are writing these rules are not necessarily intimately familiar with healthcare operations. And so I think we saw that out of the No Surprises Act. There’s a provision in there that talks about advanced EOBs. And it’s currently been delayed because the technology just does not exist to accomplish a single estimate for all services at the hospital, including everyone’s contracted rates, ancillary providers, other physicians who are not employed, as well as all the things that could happen at the hospital onto a single estimate. And the payers being able to provide that back timely as well has just proven impossible. And so as a part of the rulemaking process, yes, it’s in legislation, but as part of the rulemaking process, they’ve had to back off on that and say, “There’s development software and things that need to happen to be able to accomplish that. So, we’re not going to require it as to the letter of the law.” And so in summary, the AHA, if you’re not on a listserv with them and your organization’s a member, I would get on the listserv.

You’re going to get emails every day, which you can skim and lean on your government affairs team, and lean on your State Hospital Association to really help you with what’s coming up and when those things are items that you should really be aware of.

Kelly: Those are some great suggestions. Thanks for those. So how can revenue cycle leaders potentially impact pending legislation or proposed rules?

Rodney: Yeah, that’s a really good question, Kelly. And I think that it’s one that, again, when I was on the hospital side, I didn’t really give enough credit to that there could be impacts and there could be ways that you could provide feedback. We’ll start with rules. When CMS or HHS or any of the departments issue rules, they issue them in a proposed status first, which is key. You are able to kind of see the direction in that rule of where CMS is going. CMS is a good example, but where the departments are headed, kind of where their minds are. And you can kind of read the tea leaves a little bit with the direction of the rule. It’s in a proposed status, which means they are seeking comments. They usually open up comment periods for 30, 60, or 90 days. And they will say, “By this date, comments need to be submitted.” Anyone can submit comments. Those comments are typically public and they can be anonymous. But the CMS does read those comments and many times takes things into consideration. So, if there are things in proposed rules that you like, you should let CMS know you like it, that it would be good for your industry, it would be good for your patients, and why. Because if they get a lot of negative responses on something and no positive responses, even though people thought it was good, they may make modifications to that that are less favorable to providers. Likewise, if you think that there’s something in that proposed rule that would be harmful, whether to your organization or to your patients, you should consider commenting and providing details around why you think that, for the same reasons.

And so from a proposed rule standpoint, the comment periods and providing those comments are key. I would also say many state hospital associations, THA included, we do provide comments on, I would say, the majority of rules, especially if our members are passionate about provisions in the rule. And so as we craft our responses to proposed rules, we do lean on our members to provide us with comments, input, feedback, statistics around what that rule would mean if finalized, and what we think ways to improve the rule might be. And so I think those are some good ways to tackle rules. From a legislative standpoint, that’s a little bit more broad. At the state level, your State Hospital Association is probably the one with the most detail, and providing them with input and talking points around proposed state legislation that’s out there is a really good way to help arm your State Hospital Association as well as your state government affairs team, if you’re part of an organization that has some of those people or has contract lobbyists that are going to be working on bills, to help them craft talking points around that legislation is really helpful. At the federal level, things tend to move much slower. And so working with your State Hospital Association, again, as well as your federal government affairs people, if you have those, and even the AHA, it can be helpful as they understand what the impacts are.

We are always looking for data and statistics around what the impacts would be to hospitals if something were to pass. And site neutral has been a discussion for quite some time and continues to kind of garner some support at the federal level. It does appear that it’s still an outstanding issue, at least at the time we’re having this conversation. And who knows what will happen with that? But helping your contacts understand what the proposed changes in site neutral payments would be is a good way to arm them with more information, more talking points, so that as they’re having conversations with those federal lawmakers, that they do understand the impacts of the decisions that they are making. And again, this is one of those things that I think a lot of revenue cycle leaders think kind of happens outside of their control. And of direct control, I would agree. But I do think there are ways to influence and impact what’s coming up, whether it’s in rules or state or federal legislation. I think there are ways that revenue cycle leaders– I encourage revenue cycle leaders to engage on these topics because I think, as revenue cycle leaders, you’re going to have points and impacts and details and questions that not everyone would have. You’re going to have a unique perspective, and that perspective really needs to be heard and understood. And so, you do have a voice, and I encourage you to try to use it whenever possible.

Kelly: That is great advice, and those are some great ideas. Thank you. And thank you so much for joining us today, Rodney, and for sharing your insights on the impacts of regulations on the revenue cycle. We really appreciate it all.

Rodney: It’s been a fun conversation. Thanks for having me again, Kelly.

Kelly: Of course. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Rodney: Sure. My email address is R-A-D-A-M-S-R So, you’re happy to take emails, if someone would like to reach out that way. LinkedIn is also a good opportunity and a good way to connect. And so, if we’re not connected on LinkedIn, feel free to look me up. It’s Rodney Adams. I am in the greater Nashville area. And so, you shouldn’t have too much difficulty finding me on LinkedIn. So, send me a connection request or follow me on LinkedIn. I do post some things there from time to time around these topics, as well as others that are hot in the industry at the time, and would be happy, always happy to connect with others around some of these items because we are all truly working for the same common goal at the end. And I think the more knowledge and information that we can share, the better.

Kelly: Most definitely. Thank you for sharing that with us. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.


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