Monitoring the Pandemic: Healthcare Billing Compliance and Income Integrity Insights and Implications

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By Ritesh Ramesh, COO, Hayes

Because the Omicron variant spreads throughout the US and the delta variant continues to push COVID-19 circumstances greater, it’s a grim reminder that the COVID-19 pandemic is much from over. Though 60% of the nation is vaccinated with a number of doses and plenty of classes have been discovered by the 2020 pandemic cycle, hospitals and well being programs are making ready for a tough street forward. They’re bracing for greater utilization, staffing shortfalls, and a rise in demand for COVID-related companies resulting in a rise within the scientific and monetary strain in days and months forward.

For the reason that creation of the pandemic in 2020, healthcare organizations are attempting to mitigate compliance and income dangers. We’ll proceed to supply data-driven insights to healthcare organizations throughout and after the pandemic.

Hayes Healthcare just lately carried out an evaluation from a pattern of fifty+ massive healthcare organizations throughout the nation and gathered insights and implications for healthcare organizations regarding the present COVID-19 surge.

1. Infections began to surge in August of this yr and outpatient utilization will proceed to extend within the months forward. 

We see from our evaluation of denials knowledge that infections began elevating in August after it had bottomed out in July and peaked round September reaching ranges final seen in early spring. The months of October and November have been comparatively “excessive” in comparison with what was seen in late spring and summer time of this yr. Hayes noticed the bulk (roughly 70%) of the circumstances within the pattern are outpatient, which emphasizes the efficacy of vaccinations and different therapeutics out there to battle the severity of the illness relative to final yr. 

Healthcare organizations will see additional pressures on their outpatient utilization associated to COVID-19 companies within the coming weeks and months. There’s a heavy threat of demand outweighing capability. Organizations must plan for staffing, PPE’s and make vital selections that affect their different important non-COVID associated outpatient companies equivalent to elective surgical procedures. Compliance organizations must align their auditing plan and processes to handle this business development.

2. Hospital inpatient billing nonetheless current a big income threat when it comes to denials. 

Healthcare organizations ought to proactively deal with advanced inpatient expenses when it comes to billing, compliance, and income integrity to mitigate income dangers. Though the quantity of inpatient COVID-19 circumstances continues to be decrease than the outpatient circumstances within the present surge, the case volumes on this class are two to a few occasions the quantity seen in late spring and early summer time. This has resulted in whole denial {dollars} related to Inpatient admissions linearly growing to 2X-3X to what it was in its lowest ranges in July.  

Since a lot of the Inpatient COVID-19 circumstances are advanced, requiring a number of days of stays, companies, and expenses, organizations can mitigate monetary dangers with correct coding, scientific documentation, proactive auditing, and applicable billing submission protocols for hospital billing. Many of those expenses will proceed to draw RAC and exterior audits in 2021 and past from federal, state, and industrial payers due to its reimbursement {dollars} at stake.

3. Declare processing occasions with the payers are nonetheless comparatively quicker in comparison with the sooner a part of the yr. Proceed to watch common lag days to payers.

Through the 2020 cycle of the pandemic, guidelines round billing submission and coding have been dynamic and fluid. Many organizations delayed the discharge of claims to payers till they bought all the protocols and processes underneath management. Due to this fact, declare processing time took longer than common. 2021 represented a unique image. Common lag days, the time taken to reply by the payer after the preliminary submission of declare by the supplier, have seen incremental enhancements for hospital billing for the reason that begin of the yr to July (from a mean of 30+ days to lower than 20 days for Inpatient, from a mean of 20+ days to lower than 15 days for Outpatient). 

There might be extra strain on the declare processing occasions from the payer to the supplier. To mitigate income dangers, healthcare organizations ought to guarantee claims (most significantly, hospital claims) are correctly billed, coded, and submitted to the payer for funds with applicable scientific documentation. As soon as they obtain a denial again from the payer, suppliers ought to equip themselves with optimum income integrity processes and data-driven insights to know root causes after which observe up in a well timed method to make sure quicker cost that impacts their money movement and income.

As we strategy the second anniversary of COVID-19’s discovery within the US, healthcare organizations should stay diligent to maintain up with affected person care and the monetary challenges that an evolving pandemic deliver. It isn’t solely suppliers which can be struggling. Coders, auditors and income integrity groups have been overwhelmed with the quantity of circumstances, the complexity, and the altering coding necessities. A easy have a look at the charts above assist for instance how tough the state of affairs is when the quantity of denials doubles inside two months. Income flows have been impacted considerably and there’s no signal of issues getting higher within the close to time period. To maintain shifting ahead, give attention to schooling and corrective motion to mitigate future income and compliance threat.