ParaRev Weekly eJournal March 30, 2022

ej o u r n a l march30, 2022

Monoclonal Therapies

One More

FDA Pauses COVID-19 Therapies

FDA Authorizes Second COVID-19 Booster

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Seven Root Causes Most Common Delays And Denials

PARA Weekly eJournal: March 30, 2022

RARC CODES RELATED TO THE NO SURPRISES ACT

Under HIPAA, all payers, including Medicare, are required to use claims adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) approved by X12 recognized code set maintainers, instead of proprietary codes to explain any adjustment in the claim payment.

RARCs are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing. The following RARCs related to the No Surprises Act have been approved by the RARC Committee and were effective as of March 1, 2022.

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PARA Weekly eJournal: March 30, 2022

RARC CODES RELATED TO THE NO SURPRISES ACT

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PARA Weekly eJournal: March 30, 2022

ZERO-BALANCE CLAIM REVIEWS

cat ching up on aged account s

A CRITICAL BACKSTOP FOR AR M ANAGEM ENT STRATEGIES As payer rules and coding have become more complex and internal pressures mount to keep accounts receivable (AR) days low, denial rates and resulting write-offs have continued to climb for most hospitals. Between 2011 and 2017, denial volume soared by nearly 80 percent for the average hospital.1 The financial impact of these late or foregone collections is significant. Even though 90 percent of denials are preventable, and two-thirds are recoverable, 65 percent of claim denials are never corrected and resubmitted for reimbursement.2 A recent survey of hospital executives found that 30 percent of facilities had bad debt of between $10 million and $50 million.3

AR STRATEGIES FOR AGED ACCOUNTS Today, in the wake of often-severe cash flow problems triggered by the COVID-19 pandemic and other operational and regulatory challenges, a growing number of hospitals are partnering with third parties to implement comprehensive AR management strategies that can help reduce denials and ensure facilities collect every dollar they?re entitled to. These integrated approaches typically incorporate both internal and external elements: Hospital billing staff focus exclusively on the newest claims, then turn over unpaid balances to specialists at specific aging intervals.

Relying on external experts to pursue low-dollar, high-volume claims is often the most cost-effective way to optimize collections and minimize write-offs, since it frees up staff to concentrate on fresher, higher-dollar claims. Pre-write-off insurance collection experts well-versed in health plan policies can provide an additional safeguard to help prevent legitimate claims, regardless of age or size, from going uncollected. A comprehensive approach will help organizations obtain hard collectible dollars from the full spectrum of aged accounts, including pre-write off claims and even from closed balance accounts.

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PARA Weekly eJournal: March 30, 2022

ZERO-BALANCE CLAIM REVIEWS

BOOSTING CASH FLOW WITH ZERO-BALANCE REVIEWS OF CLOSED BALANCE ACCOUNTS One critical element in a comprehensive AR management strategy is a zero-balance claims review. Zero-balance reviews are essentially forensic audits of written-off claims. Thorough, closed-balance reviews can validate claims integrity and maximize contractual revenue for all payers. They are designed to assess whether the factors that initially caused a payer ?s denial can be mitigated to secure retroactive reimbursement.

While some may assume that pursuing old write-offs isn?t likely to be productive, experts skilled at identifying common mistakes that frequently result in denials can recover up to one percent of a hospitals total net patient revenue. For large hospitals and health systems that may generate hundreds of millions of dollars annually, this can translate into a significant amount of found revenue.

FOUR STEPS TO IM PROVING COLLECTIONS THROUGH AN EXTERNAL ZERO-BALANCE REVIEW Most healthcare systems or organizations typically don?t have the time, resources or expertise to conduct in-depth reviews of denied or unpaid aged claims. External reviews consequently can provide the extra scrutiny needed to potentially capture revenue from denied, underpaid and unpaid claims. Zero-balance reviews of closed balance accounts performed by an experienced partner represent a final safety net at the end of the revenue cycle management process, again freeing up staff to concentrate on fresher, higher-dollar claims.

Her e ar e t h e f ou r pr im ar y st eps t h at sh ou ld be in clu ded in a zer o-balan ce r eview : 1. Scr u t in ize con t r act s Specialists review all payer contractual agreements to identify areas of underpayment risk.

This process is conducted in conjunction with hospital contracting staff and attorneys to help clarify the facility?s expectations or intent with respect to specific contract provisions. Not infrequently, specialists identify ambiguous language that leaves the facility vulnerable to underpayments or common reimbursement methodologies that can be exploited by payers to reduce reimbursement.

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PARA Weekly eJournal: March 30, 2022

ZERO-BALANCE CLAIM REVIEWS

Contract problems sometimes can be as simple as a grammatical error or word choice: A clause that should have included ?and?instead of ?or,?or vice versa, depending on the anticipated scenario, can lead to reoccurring underpayments. Language like this may be causing significant underpaid revenue unbeknownst to revenue cycle staff. Experts also flag any coding changes that may have occurred since the contract was executed to ensure updates have been made and reimbursements continue to be paid at appropriate levels.

2. Evalu at e disch ar ge f iles After the contract review is completed, zero-balance specialists download a full set of discharge files for a specific time frame, usually two full years of data for all payers, including Medicare, Medicare Advantage, Medicaid, Medicaid HMO, and commercial carriers.

Par aRev processes the data files through a proprietary application that has been custom-programmed with each payer ?s contract specifications. This process produces an independent payment analysis that isn?t reliant on the hospital?s contractual expected amounts to identify both underpayments and areas where the hospital?s model may be deficient or inaccurate.

Given the inherent limitations of existing billing platforms in calculating complex reimbursements? such as payments due from a secondary payer or more accurate outpatient coding? greater accuracy is usually achieved.'

3. Per f or m an in -dept h , 360-degr ee r eview Once the subset of closed accounts is identified for potential additional revenue, an in-depth review is performed to pressure-test the integrity of the claim and the subsequent reimbursement. This step relies on the external team?s collective experience to research each claim and maximize the revenue potential unique to that claim and payer, focusing on industry changes, coding best practices, and the contractual intent for each hospital. When accounts are verified through this review as underpaid, Par aRev ?s experts work with the payers to deliver the additional revenue to the hospital?s bottom line.

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PARA Weekly eJournal: March 30, 2022

ZERO-BALANCE CLAIM REVIEWS

4. Recom m en d im pr ovem en t s From this extensive review process and subsequent trend analysis, recommendations can be made about how hospitals can optimize collections through implementation of coding best practices for specific procedures or drugs. One example: a hospital may not be billing properly for expensive new drugs that are FDA-approved but do not have an HCPCS code assigned.

Medicare and most commercial payers have specific, often complex requirements for reimbursing for unclassified drugs, and external experts can help in resubmitting claims with this correct coding to achieve proper reimbursement.

In addition to flagging coding mistakes, the zero-balance claims analysis also identifies payer deficiencies, whether they?re one-off events or reoccurring, systemic issues. Working withing appropriate contractual claim and appeal submission time frames, Par aRev will work with the hospital staff to resubmit corrected claims to the payer, and, in instances when the payer is at fault, bring the problem to the attention of provider relations and help prepare for arbitration if necessary.

A SECOND SET OF EYES The zero-balance review can produce immediate benefits, in terms of recovered reimbursement on written-off claims, as well as longer-term reductions in inaccurate coding, denials and write-offs. Working in partnership with hospital staff, experts identify process improvements and help implement staff training to reduce and eliminate denial root causes. Ultimately, zero-balance reviews provide expert oversight to scrutinize the all-important denial arena.

This can help produce lasting solutions that improve collections while ensuring optimal compliance. Amid the current challenges in healthcare, this capability helps hospitals not only collect every dollar they are owed, but also allows them to focus on other, equally pressing areas of operations.

1 Kelly Gooch, ?4 ways hospitals can lower claim denial rates,? Becker ?s Hospital CFO Report, Jan. 5, 2018 2 Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015 3 ?Bad Debt Exceeds $10M at a Third of Organizations, But Lack of Confidence Exists in How Much is Recoverable,? Cision PR Newswire. June 19, 2018.

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PARA Weekly eJournal: March 30, 2022

FDA PAUSES CERTAIN COVID-19 MONOCLONAL THERAPIES

On January 24, 2022, the FDA revised the Emergency Use Authorization for the Regeneron drug combination (casirivamab and imdevimab and the Eli Lilly drug combination (bamlanivimab and etesevimab). Because studies indicate these therapies are less effective in targeting the most prevalent COVID-19 variant, Omicron, the FDA limits the use of these monoclonals to patients infected with or exposed to COVID-19 variants receptive to these therapies.

https://www.phe.gov/emergency/events/COVID19/investigation-MCM/ Bamlanivimab-etesevimab/Pages/default.aspx

Other FDA-approved therapies to treat patients with mild to moderate COVID-19 and are at high risk for hospitalization, severe disease, or death include: - Infusions of Veklury (remdesivir), bebtelovimab, or sotrovimab (all deemed effective against Omicron, which currently accounts for most COVID-19 infections in the United States.)

- Convalescent plasma (blood product transfusion) - Antiviral oral medications Paxlovid and molnupiravir;

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PARA Weekly eJournal: March 30, 2022

FDA PAUSES CERTAIN COVID-19 MONOCLONAL THERAPIES

PARA offers papers with detailed information at the following links: https://apps.para-hcfs.com/para/Documents/EUA%20Issued%20for%20Antiviral %20Pills%20to%20Treat%20Covid.pdf

https://apps.para-hcfs.com/para/Documents/COVID-19%20Monoclonal%20Product% 20and%20Administration%20Codes.pdf

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PARA Weekly eJournal: March 30, 2022

MONITOR "MISCELLANEOUS" CHARGEMASTER LINE ITEM USE

Some facility departments find it useful to use a ?miscellaneous? chargemaster line item to use when an unusual drug or supply needs to be charged, but there is no established chargemaster line item that fits the item.A ?miscellaneous? charge allows the user to enter the price, and even a HCPCS code, for each charge instance.This saves both time and work required to create a new chargemaster line for items that are unlikely to be charged again.Here are some examples of ?miscellaneous? line items as displayed in the PARA Dat a Edit or :

Certain drugs and implants may generate additional reimbursement on an outpatient claim when billed with the appropriate HCPCS and units.

- Expen sive dr u gs are separately payable under Medicare?s OPPS reimbursement program, but the HCPCS and units billed must be appropriately reported in order to be paid. Even Critical Access Hospitals, which are paid by Medicare on a cost-reimbursement basis, risk losing reimbursement for expensive drugs and implants when submitting claims to non-Medicare payers which pay per unit according to the HCPCS - Su pply ch ar ges such as implants and off-the-shelf prosthetics and orthotics should be recorded with the appropriate HCPCS whenever possible; failure to report the HCPCS can result in lost reimbursement and billing issues for procedures which require a separate implant HCPCS to be reported on the same claim.

The use of ?miscellaneous? charge lines should be carefully monitored in order to avoid lost reimbursement.Some department personnel may find it more convenient to use the miscellaneous charge code rather than to look up the appropriate chargemaster line item for the for pharmacy or supply to be charged.

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PARA Weekly eJournal: March 30, 2022

MONITOR "MISCELLANEOUS" CHARGEMASTER LINE ITEM USE

In a recent audit of a ?miscellaneous? pharmacy charge line, PARA found two expensive drugs were charged using the ?miscellaneous drugs? charge line, although there were alternative established chargemaster procedure codes that would have reported the drug correctly.

This indicates that the staff inappropriately used the ?misc? charge, perhaps because it was easier than looking up the correct charge code for those drugs.

Department managers which permit staff to use a ?miscellaneous? charge line should regularly audit charges generated using that item no less frequently than once a week.

Managers have a responsibility to ensure that staff utilize ?misc? line items appropriately, and to ensure the facility captures appropriate reimbursement for services that require HCPCS reporting on an outpatient claim.

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PARA Weekly eJournal: March 30, 2022

FDA AUTHORIZES SECOND COVID-19 BOOSTER

In a statement released on March 29, 2022, the FDA authorized a second Covid-19 vaccine booster for immunocompromised individuals and people aged 50 and older. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19update-fda-authorizes-second-booster-dose-two-covid-19-vaccines-older-and

The emergency use authorization (EUA) revision includes second Covid-19 booster doses for both Pfizer and Moderna vaccines: - Administration of Pf izer or M oder n a COVID-19 booster dose to individuals 50 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine - Administration of a second booster dose of Pf izer COVID-19 vaccine to individuals 12 years of age and older with certain kinds of immunocompromised conditions. The administration is authorized at least 4 months after the receipt of a first booster dose of any authorized or approved COVID-19 vaccine - Administration of a second booster dose of the M oder n a COVID-19 Vaccine at least four months after the first booster dose of any authorized or approved COVID-19 vaccine to individuals 18 years of age and older with the same certain kinds of immunocompromised conditions COVID-19 vaccine products and administration codes may be found through the following link: https://apps.para-hcfs.com/para/Documents/COVID-19%20Vaccine%20Product%20 and%20Administration%20Codes%20(02-17-2022).pdf

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PARA Weekly eJournal: March 30, 2022

HRSA COVID-19 UNINSURED PROGRAM TO STOP ACCEPTING CLAIMS

Due to a lack of funds, on M ar ch 22, 2022, HRSA Covid-19 Uninsured Program (UIP) will stop accepting claims for testing and treatment.

Beginning Apr il 5, 2022, the program will no longer accept vaccination claims submitted for the Uninsured Program. HRSA will continue to adjudicate and pay claims submitted based on the availability of remaining funds.

We remind all providers participating in the CDC COVID-19 Vaccine Program of the following requirements: - Providers must administer the vaccine at no cost to the individual (may also not balance bill) - Providers cannot charge an office visit (or other fees or services) if the individual received only the vaccine - Providers may not deny vaccines based on insurance coverage or out-of-network status HRSA provides a webpage for additional information and alternate resources for uninsured patients seeking Covid-19 treatment or services: https://www.hrsa.gov/coviduninsuredclaim/submission-deadline

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PARA Weekly eJournal: March 30, 2022

FINDING CASH IN AN UNLIKELY REVENUE STREAM

a casest udy: how a l ar ge heal t h syst em r educed ext r emely- aged account wr it e- of f s.

OVERVIEW A large California health system's fiscal year-end was fast approaching and was faced with a large subset of inventory at 386 days old.

It is well known that the longer a claim goes unresolved, the less money there is to collect and the general consensus for aged claims exceeding a year is to write it off. The system wasn?t ready to accept the losses and was not in the position to add resources.

The system decided to partner with Par aRev to collect any amount that could be saved, and signed on for a one-time, fiscal year-end project.

BACKGROUND The California health system?s fiscal year-end was at the end of March, and upon agreement, Par aRev received the placements the first week of February with a four month agreement to boost their year-end collections. This left Par aRev with two months to collect as much of the $9 million in placements as possible before the year-end, plus an extra two months to collect anything else that could be reclaimed.

The age of the accounts and the denial mix were two major contributors to the challenge of resolving this inventory.

Thirty-one percent of the accounts were Managed Medicare and Medicaid with an average age of 409 days. The non-government payers consisted of 69% of the accounts and had an average age of 376 days.

Out of the total denial mix, 40% were inpatient contractual reviews and 33% were clinical based rejections.

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PARA Weekly eJournal: March 30, 2022

FINDING CASH IN AN UNLIKELY REVENUE STREAM

EXECUTION Par aRev utilized their process of combined robotic analytics and intelligent automation along with specialized representative experts to collect on the $9 million inventory that was over 386 days old. This process allowed Par aRev to quickly identify that out of the $9 million in inventory, $7 million had a chance of collectability while the remaining $2 million was labeled dead inventory. In order to accomplish the goal of making low collectible accounts collectible, strict oversight was required.

Par aRev then organized and distributed the collectible inventory to the remediation specialists whose skill set matched that of the inventory and had them challenge the carriers to the highest degree. The dead inventory was distributed to the analyst team to complete the proper adjustments and to identify exactly what went wrong.

After the analysts identified the actual root causes, the problems were compiled into a presentation for the health system, explaining the pain points and how the system could avoid these denials in the future. Following the set up of the structure of collecting on these accounts, experienced management constantly monitored and calibrated the staff to optimize for efficiency.

This strategy proved to be so successful that the health system requested an extension of the contract to have Par aRev continue to collect on the accounts.

RESULTS The fiscal year-end project lead with $9 million in placements at 386 days and Par aRev was able to obtain a 34% net collection rate, with a 27% gross rate over a 9-month period.

In the four months Par aRev was originally given to work the accounts, a collection growth of $500k per month was achieved for totals of: - $980k by the end of March - $1.5 million by the end of April - $2 million by the end of May

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Par aRev Quickly identified $7 million in inventory as being collectible, collected $2 million within four months, and highlighted root-cause trending in the following areas: - Clinical (37%) - Contractual Underpayment (30%) - Coding and Billing (27%) - Coverage and Registration (6%)

PARA Weekly eJournal: March 30, 2022

FINDING CASH IN AN UNLIKELY REVENUE STREAM

At the end of the four months, Par aRev collected $2 million and identified that there was $2 million in opportunities remaining and continued to collect on them as the one-time service had grown into a true partnership.

After pushing back on the insurance carriers for lack of payment, Par aRev was able to collect $2.5 million for a net collection rate of 34%. In addition to bringing in the system?s hard-earned cash, Par aRev also provided trending insights into the denials that impacted their bottom line and how to avoid these denials in the future.

This included detailed trending on top denial areas including: clinical (37%), contractual underpayments (30%), coding, billing, and rebilling (27%), and coverage and registration issues (6%). In the end, Par aRev successfully collected on a subset of inventory that is not typically highly collectible with a good turnaround. Par aRev can succeed where others have been unable to and areas that are not necessarily thought of as collectible.

CONCLUSION Par aRev ?s scalable, client-specific accounts receivable resolution and recovery solutions allow hospitals to systematically address problem claims across the full AR spectrum- from long term to a project basis. With the addition of our proprietary intelligent automation working alongside our remediation ?Som e people call specialists, we?re able to resolve all claims, regardless of size or age- bringing in the cash and providing real-time t h em selves ven dor s trending presentations to provide insight into what is truly w h en t h ey h ave n o driving your delayed payments and offering solutions to bu sin ess callin g prevent these occurrences from happening in the future.

Hospitals looking for a new AR recovery and resolution partner can look to Par aRev. Rates are contingency based, so there are no hidden nor cancellation fees.

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t h em selves ven dor s, bu t Par aRev does,? said Cor por at e Dir ect or of Pat ien t Fin an cial Ser vices.

PARA Weekly eJournal: March 30, 2022

NON-ESRD DIALYSIS FACILITY BILLING AND CODING

Medicare provides special coverage for persons with end-stage renal disease (ESRD.) Eligibility for Medicare benefits based on ESRD works differently than other types of Medicare eligibility ? individuals who meet other eligibility requirements can sign up when diagnosed with ESRD, regardless of age.

There is a coordination of benefits period of 30 months for beneficiaries who qualify for Medicare based on ESRD and who also have group health coverage ? the group health coverage is primary during the 30-month waiting period. After 30 months, Medicare ESRD coverage becomes primary.Consequently, many patients with ESRD are Medicare beneficiaries.

One of the most common services that ESRD beneficiaries may require is dialysis.The two most common types of dialysis are hemodialysis and peritoneal dialysis: - Hem odialysis? ongoing dialysis (3 to 5 times a week) that cleans the blood, usually provided at an outpatient ESRD dialysis center. Hemodialysis patients typically have an access port in the arm - Per it on eal dialysis-- ongoing daily dialysis that collects waste from the blood by washing the empty space in the abdomen (peritoneal cavity). It can be done in the home setting, or within a facility in the outpatient or inpatient setting. The peritoneal dialysis access port is in the abdomen Coding for outpatient dialysis at a non-ESRD facility differs depending on the beneficiary?s coverage (ESRD or non-ESRD), eligibility for Part A or Part B Only, and the type of dialysis service provided.

ESRD Ben ef iciar ies: Medicare covers routine dialysis treatments for an ESRD beneficiary only when furnished in an ESRD-certified facility. However, Medicare will cover emergency dialysis treatments in an outpatient department of a hospital, and dialysis services performed for ESRD beneficiaries during an acute inpatient hospital stay.

Non -ESRD ben ef iciar ies are not ESRD patients, but may require dialysis to treat a non-ESRD condition.Medicare covers outpatient dialysis performed for a non-ESRD beneficiary at a non-ESRD facility.

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PARA Weekly eJournal: March 30, 2022

NON-ESRD DIALYSIS FACILITY BILLING AND CODING

The following table illustrates the three HCPCS codes which represent dialysis procedures performed in a non-ESRD outpatient hospital facility setting:

Links and excerpts from the Medicare Claims Processing manual are provided below: https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/ Downloads/clm104c04.pdf

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PARA Weekly eJournal: March 30, 2022

NON-ESRD DIALYSIS FACILITY BILLING AND CODING

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PARA Weekly eJournal: March 30, 2022

NON-ESRD DIALYSIS FACILITY BILLING AND CODING http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf#

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PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

The7 Most Common Root Causes f or Denial s and Del ay ed Account Resol ut ion Pay ment del ays and wr it e- of f s t r igger ed by insur ance denial s r epr esent a ser ious and gr owing f inancial concer n f or most hospit al s and heal t h syst ems.

Despite concerted efforts across the industry, the average 350-bed hospital saw denial write-offs jump by 79% between 2011 and 2017, from $3.9 million to $7 million.1 All told, approximately 9% of $3 trillion in U.S. hospital claims were initially denied in 2016, while the administrative costs of reworking denials are now approaching $9 billion annually.2 Even with this huge outlay, however, only about 35% of payer rejections are ever reworked and resubmitted.3 The struggle to stem chronic losses associated with rejected insurance claims reflects the complex nature of the reimbursement cycle. In a system that requires inputs from multiple points along the care continuum and is marked by frequent rule and policy changes, illuminating the primary causes of rejections and creating tools to resolve them can be enormously difficult.

That?s why it can be cost-effective to partner with a qualified third-party that possesses the technology and expertise required to help hospitals isolate, identify and remediate issues that result in unresolved claims. Par aRev is a leading accounts receivable A/R resolution and recovery management firm with more than 20 years?experience helping hospitals address rejected and aging A/R. Through a significant investment of time and resources, we?ve developed advanced intelligent automation capabilities that help us quickly understand how, why and where payment delays are occurring.

Root causes can range from flawed internal processes and technology errors to insurance and clearinghouse mistakes. Regardless of the reason for the unresolved claim, it?s important to remember that while only about two-thirds of denials are recoverable, 90% of them can be prevented.4 21

PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

Hospital revenue management staff should therefore focus on developing a comprehensive knowledge base around the issues that trigger payment delays, either independently or in partnership with an A/R follow-up vendor. The hospital will then be positioned to systematically address the full spectrum of shortcomings that contribute to payment delays and write-offs. The following list reflects the seven most common areas from which hospital claim delays typically arise ? based on our clients?experiences nationwide ? as well as general strategies for mitigating the problems.

1. UTILIZATION This category accounts for 25% of all denied charges among Par aRev clients and includes the clinical areas of medical necessity, pre-authorization, DRG downgrades and experimental treatments. Insurance companies will often challenge whether a specific treatment was medically required, whether the level of care provided corresponded to the underlying morbidity, or whether the length of stay was justified.

Failure to obtain a necessary pre-authorization from the carrier for a specific treatment likewise can trigger a utilization denial. Still another common utilization denial involves challenges to the provision of emergency care. Experimental treatments, such as PET scans, 3D mammograms and computer-aided detections (CADs), also can result in denials.

Overcoming utilization denials requires that hospitals be well-versed in an insurance company?s clinical policy bulletins, which describe what the carrier will and will not cover, what they consider to be medical necessity, and the treatments they deem to be experimental.

At the same time, hospitals must be ready to promptly and consistently develop appeal narratives that make a strong medical case for the treatment provided. Par aRev relies on trained personnel, including RNs and registered health information technicians (RHITs), to write its appeals.

Denials relating to authorizations also can stem from something as simple as an authorization code not being included in the appropriate field of the insurance claim. By reviewing denial information with intelligent automation capabilities, these kinds of mistakes can be quickly isolated and addressed.

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PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

2. COVERAGE Unresolved claims due to coverage issues make up about 21% of denied charges for ParaRev clients. As the name implies, coverage denials involve real or perceived errors or omissions surrounding health plan coverage limits. One surprisingly frequent problem in this area involves the willingness of many hospitals to ignore patient eligibility rejections flagged by their eligibility verification system.

Whether this tendency is the result of carelessness or reflects staff concerns about claim submission quotas, the net effect is that claims are rejected, and hospitals often are left with little recourse but to balance-bill the patient. Issues surrounding the coordination of benefits (COB) or billing the appropriate insurer in cases where the patient has multiple coverages, represent another frequent source of denials.

COB denials arise when a specific policy is no longer in effect or has been superseded by a replacement policy. One common example involves billing straight Medicare when a Medicare Advantage managed care policy is the primary coverage vehicle. COB issues also can arise due to uncertainty surrounding worker ?s comp, auto or personal injury coverage. In these instances, resolution typically involves carefully tracing the policy guidelines as well as the nature of the illness or injury to determine which coverage is most appropriate.

3. CONTRACTUAL Payment delays and rejections stemming from contractual issues make up the third-largest category of denied charges, at 17%.

Contractual denials can involve a wide range of issues. But one of the most common entails payer underpayments for specific services like surgery, ED, lab and radiology, therapies and observation.

Denials also can arise over misinterpretations regarding per diems, bundled payments for multiple procedures and carve-outs. Root causes can be as simple as the inclusion on the claim of the wrong plan code (HMO vs. PPO), or as complex as a miscalculation of a stop-loss limit. Determining stop loss limits for inpatient claims frequently must be done by individuals, since the process involves multiple variables and equations that typically are too complex to resolve through contract management software embedded rules.

The failure to maintain an accurate fee schedule by loading appropriate contract data into the hospital?s contract management application is another common cause of denials.

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PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

Constant attentiveness is therefore required to ensure that the contract management software is up-to-date. In addition, the careful application of ambulatory payment classifications (APCs) for outpatient services is important for calculating expected reimbursement. Site liability rejections involve denials stemming from the location where the service was performed.

Because of division of financial responsibility agreements, conflicts can arise over whether the payer or site is ultimately responsible for covering the service. In avoiding contractual-related denials, it is essential that hospital staff be cognizant of, and responsive to, the multiple deadlines associated with the filing and appeals process. These time limits can include deadlines for submission of medical records, corrected claims, appeals, and reconsiderations. Creating the capability to automatically track and flag deadlines in real-time therefore is critically important.

4. CODING AND BILLING Coding and billing issues result in about 15% of all denied charges among ParaRev?s client base.

A common problem involves Reason Code 97 rejections triggered by the failure of the hospital team to turn on National Correct Coding Initiative (NCCI) edits. The edits basically provide a system of checks designed to prevent bundling/unbundling issues due to inappropriate CPT© and HCPCS code usage, as well as inappropriate combinations of codes.

Crosswalks, which map or translate specific codes from one code set to another, also are a frequent source of denials. Minimizing the issue usually requires rule creation or edits in software coding applications.

Demographic errors can include incorrect and/or outdated patient information collected by registration staff before or at the time of service and are a consistent source of denials.

Par aRev relies on intelligent automation to categorize the type of rejection, which then allows the hospital to adjust its internal application to focus on the highest-priority demographic omission or mistake.

Finally, filing errors, including mistakes in value and occurrence codes and National Drug Code (NDC) application, account for a significant portion of code-related denials. The failure to designate the patient responsibility portion of the claim, for example, can cause the entire claim to be rejected.

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PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

5. SUBM ISSION/ RE-BILLING Denials triggered by submission problems are responsible for about 15% of all denied charges.

Failure to include the primary EOB, crossovers between supplemental and primary insurance and missing medical records are common rejection reasons.

Par aRev ?s technology can quickly verify which missing documents are necessary for successful resubmission. Problems also occur due to bugs in the hospital?s electronic claims submission software or issues at the clearinghouse. Some clearinghouses, for example, are not properly equipped to efficiently process paper claims.

As a result, the claim can often sit for an inordinate length of time. Continual communication with the clearinghouse is therefore important to ensure no reoccurring log jams or hidden delays.

6. CASH POSTING This category of issues produces about 4% of denied charges and frequently involves determining the appropriate allocation of unapplied cash. For example, assessing the differences between recoupments, or refunds for overpayments, and offsets, which involve allocating unspecified funds to existing claims, requires careful analysis of policy language and covered services previously paid for.

7. PROCESS DELAYS Process issues account for three percent of denied charges and usually involve payers taking an excessive amount of time to process a claim for reasons unrelated to the claim itself. It is therefore important for hospitals to identify and isolate payment delay patterns involving specific payers. This enables prompt followup with the carrier to ensure payments are made in accordance with the terms of the existing contract.

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PARA Weekly eJournal: March 30, 2022

SEVEN MOST COMMON ROOT CAUSES FOR DELAYS OR DENIALS

A Wor k in g Par t n er sh ip Par aRev delivers a wide array of capabilities designed to quickly identify the causes of denials, including those involving high-volume, low-dollar value claims. Many vendors ignore or discount these types of denials due to either technology limitations or a desire to focus on high-dollar claims and the greater renumeration that comes with resolving them.

Par aRev also provides clients with ongoing consultation and process engineering recommendations to help prevent denials from occurring in the first place. For truly effective denial remediation and prevention, however, it is important for hospitals to understand that aligning with an A/R follow-up management vendor requires ongoing collaboration and communication between the parties.

That means essentially treating the vendor as an extension of the hospital?s internal business office. Sharing desk procedures and process flows, collaborating about known payer issues, providing access to managed care contracts, EDI files and EMR, clearinghouse, correspondence and imaging systems all are necessary to maximize the return on any A/R management firm engagement.

Healin g an Open Wou n d For many hospitals, denials are a festering financial wound that refuses to heal. Some organizations have resigned themselves to living with the write-offs associated with denials, but this approach is short-sighted in today?s increasing challenging economic environment. With an average operating margin of just 2.7%, hospitals can?t afford not to follow up on every dollar owed them for service.5 That?s why hospitals should consider partnering with a qualified third-party to develop and implement a comprehensive A/R resolution strategy. By reducing the incidence of denials and resolving those that do occur more quickly, cash flow is increased, write-offs are reduced, and administrative staff time can be used more efficiently.

1

Kelly Gooch, ?4 ways hospitals can lower claim denial rates,? Becker ?s Hospital CFO Report, Jan. 5, 2018

2

Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually,? HealthLeaders, June 26, 2017

3

Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015

4

Morgan Haines, ?An ounce of prevention pays off: 90% of denials are preventable,? Advisory Board, Dec. 11, 2014

5

Ayla Ellison, Jessica Kim Cohen, ?224 hospital benchmarks,? Becker ?s Hospital Review, June 25, 2018

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PARA Weekly eJournal: March 30, 2022

Click an yw h er e on t h is page t o be t ak en t o t h e f u ll on lin e docu m en t .

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PARA Weekly eJournal: March 30, 2022

TUESDAY WEBINARS: COMPLYING WITH THE NO SURPRISES ACT

t ime is r unning out .

PARA exper t s ar e pr ovidin g a f r ee w ebin ar each Tu esday design ed t o h elp h ospit als u n der st an d an d com ply w it h t h e r equ ir em en t s u n der t h e No Su r pr ises Act .

Ever y Tu esday 11:30 am PST

Sign Up By Click in g HERE, Or Scan Th e QR Code

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PARA Weekly eJournal: March 30, 2022

APRIL 2022 HCPCS UPDATE RELEASED

Medicarerel easedtheHCPCScodeupdatefor April 1, 2022inearly March.However, asof March14, 2022, theOPPSAddendumBupdatefil eisnot avail abl e, thereforeweareunabl etoreport whether thenewHCPCSare payabl eunder OPPSat thistime.

PARAwil l publ ishupdates astheinformationisrel eased.

Four HCPCS for drugs will change; the code pairs are provided in the table below:

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PARA Weekly eJournal: March 30, 2022

APRIL 2022 HCPCS UPDATE RELEASED

Seven new HCPCS were assigned to drugs and biologics which did not have a previous HCPCS assignment ? including the HCPCS for Remdesivir, which was announced in January, 2022:

Nine new HCPCS for skin substitutes were added ? however, the classification of the new HCPCS as ?high cost? or ?low cost? skin substitutes is not yet published:

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PARA Weekly eJournal: March 30, 2022

APRIL 2022 HCPCS UPDATE RELEASED

One HCPCS for an Appropriate Use Criteria Clinical Decision Support Mechanism was discontinued:

A few new HCPCS were assigned to report miscellaneous new supplies/devices:

Three new HCPCS for reporting surgical procedures were added:

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PARA Weekly eJournal: March 30, 2022

APRIL 2022 HCPCS UPDATE RELEASED

The full April 2022 HCPCS file release is available at the following link: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update

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PARA Weekly eJournal: March 30, 2022

FAQ: GOOD FAITH ESTIMATES IMPLEMENTATION

CMShas publ ished a compr ehensiv e f r equent ly asked quest ions document cov er ing t he impl ement at ion of good fait h est imat es f or unisur ed and sel f - pay pat ient s. cl ick on t heimagebel ow t o v iew t heent ir e, inf or mat iv edocument .

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

unpacking t he"no sur pr ises act ".

The No Surprises Act (NSA) is a federal law which went into effect on January 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers in an in-network facility.

The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, healthcare providers and health care facilities must be prepared to: 1. Publicize and disseminate a ?Disclosure Notice? which informs beneficiaries of group health plans of their rights under the No Surprises Act; and 2. Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and 3. Provide uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility.

4. Present a Notice and Consent form, with an estimate of charges, to a beneficiary of a group health plan who chooses to receive services from an out-of-network facility or provider and submit a claim to the health plan.

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

DISCLOSURE NOTICE As of January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf insured. eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: 1. Restrictions on providers and facilities regarding balance billing in certain circumstances 2. Any applicable state laws protecting against balance billing 3. Contact information for appropriate state and federal agencies if the individual their rights have been violated

believes

RIGHT TO RECEIVE A GOOD FAITH ESTIM ATE NOTICE All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

GOOD FAITH ESTIM ATES TO UNINSURED/ SELF PAY When discussing the good faith estimate it is important to know a few terms: - A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law.

- A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.

- The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.

- A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider.

An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility.

At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y.

The following list was provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities.

A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 37

PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS The Good Faith Estimate process that requires facilities and providers to transmit estimates to health plans, is still on hold.

NOTICE AND CONSENT The Notice and Consent is being enforced for those rare instances when the patient has a choice of providers and chooses to receive services from an out-of-network facility or provider.

Situations when a patient does not have a choice of providers and cannot be requested to sign a consent waiving their balance billing protections in an in-network facility are: - When receiving services that are considered ancillary services: - Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology - Items and services provided by assistant surgeons, hospitalists, and intensivists - Diagnostic services, including radiology and laboratory services - Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility Balance billing is prohibited in all emergency situations, even those that arise during a service that is being provided under a written consent. Any charges related to that emergency cannot be balance billed until the patient is deemed stable, as defined in the NSA ? able to transport to another facility by non-medical transportation.

In the event the patient requires a higher level of care that requires transport, the EMTALA guidelines take precedence. A patient admitted to an out-of-network facility from an emergency department who is then considered stable, must be presented with a notice and consent if they choose to continue treatment in the out-of- network facility. If the consent is signed, the out-of-network facility can balance bill for charges incurred after the provider documents that patient is stable, as defined in the NSA ? able to transport to another facility by non-medical transportation. Ancillary services cannot balance bill even after the patient is considered stable.

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PARA Weekly eJournal: March 30, 2022

2022 REQUIREMENTS -- UPDATED

eCFR :: 45 CFR Part 149 Subpart E ? Health Care Provider, Health Care Facility, and AirAmbulance Service Provider Requirements

The Notice and Consent form, with an estimate of all charges, must be presented to the patient for a signature.

- This form must be available in the 15 most common languages in the geographical area. If the individual?s preferred language is not among those 15, a qualified interpreter must be made available to assist the patient with understanding their rights.

- The form must be provided at least 72 hours prior to scheduled services, when they are scheduled at least 72 hours out. When services are scheduled and performed on the same day, the document is required to be presented at least 3 hours before the services are rendered.

- The patient must be provided with a signed copy and a signed copy must be maintained in the medical record in the same manner as all other required documented.

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PARA Weekly eJournal: March 30, 2022

MLN CONNECTS

PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e!

Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!

Th u r sday, M ar ch 24, 2022

New s -

Additional Residency Positions: Apply by March 31 Long-term Care Hospitals: March Preview Period Ends April 6 Inpatient Rehabilitation Facilities: March Preview Period Ends April 6 Home Health Quality Reporting Program: Review Your Preview Reports Physicians, Teaching Hospitals, Physician Assistants, & Advanced Practice Nurses: Register in the Open Payments System Long-term Care Facilities: Quality Measure Rating Threshold Changes Lipid Panel Testing: Comparative Billing Report in March

Com plian ce -

DMEPOS Standard Written Order Requirements

Claim s, Pr icer s, & Codes -

ICD-10 Procedure Codes: Comment by April 8 ICD-10 Diagnosis Codes: Comment by May 9

M LN M at t er s® Ar t icles -

April Quarterly Update for 2022 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Quarterly Update to the End-Stage Renal Disease Prospective Payment System (ESRD PPS)

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PARA Weekly eJournal: March 30, 2022

r a n s mi t t a l s

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Ther e w er e THIRTEEN new or r evised Tr ansmittal r el eased this w eek .

To go to the ful l Tr ansmittal document simpl y cl ick on the scr een shot or the l ink .

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PARA Weekly eJournal: March 30, 2022

TRANSMITTAL R113220OTN

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TRANSMITTAL R11317CP

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TRANSMITTAL R11318CP

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TRANSMITTAL R11329CP

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TRANSMITTAL R11309CP

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PARA Weekly eJournal: March 30, 2022

TRANSMITTAL R11296BP

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TRANSMITTAL R11299CP

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TRANSMITTAL R11301CP

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TRANSMITTAL R11302CP

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PARA Weekly eJournal: March 30, 2022

TRANSMITTAL R11307PI

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TRANSMITTAL R11303CP

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TRANSMITTAL R11305CP

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TRANSMITTAL R11304CP

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ed l ea r n s

Ther e w er e FOUR new or r evised MedLear n r el eased this w eek .

To go to the ful l Tr ansmittal document simpl y cl ick on the scr een shot or the l ink .

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PARA Weekly eJournal: March 30, 2022

MEDLEARN MM12615

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MEDLEARN MM12679

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MEDLEARN MM12666

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MEDLEARN MM12676

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