RCM encompasses the processes involved in tracking and collecting patient service revenue, from the initial registration and appointment scheduling to the final payment of balances. Failure to comply with regulatory requirements can result in financial penalties, legal consequences, and damage to an organization’s reputation.
In this article, we’ll delve into the most recent regulatory changes impacting RCM and their implications for healthcare providers.
The No Surprises Act
Effective January 1, 2022, the No Surprises Act aims to protect patients from unexpected medical bills, particularly in emergency situations and when receiving out-of-network care.
This legislation has far-reaching implications for RCM processes, including:
Billing Transparency Requirements
The No Surprises Act mandates that healthcare providers provide upfront cost estimates to patients for scheduled services, enabling them to understand their potential financial responsibilities. This requirement necessitates changes in the way providers communicate pricing information to patients during the pre-service phase of the revenue cycle.
Out-of-Network Billing Limitations
The act prohibits surprise billing for emergency services provided by out-of-network facilities or providers, as well as certain non-emergency services provided by out-of-network providers at in-network facilities. This change impacts the way providers negotiate rates with insurance companies and manage out-of-network claims.
Independent Dispute Resolution Process
In cases where providers and payers cannot agree on a payment amount for out-of-network services, the No Surprises Act establishes an independent dispute resolution process. RCM teams must familiarize themselves with this process and ensure that they have the necessary documentation and procedures in place to participate effectively.
Expansion of Price Transparency Requirements
Building upon the price transparency initiatives introduced in the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has continued to implement regulations aimed at increasing price transparency in healthcare.
These requirements include:
Hospital Price Transparency
Effective January 1, 2021, hospitals are required to provide clear, accessible pricing information online for standard services and items, including negotiated rates with third-party payers. This information must be updated annually and presented in a consumer-friendly format.
Insurer Price Transparency
As of January 1, 2023, most group health plans and health insurance issuers in the individual and group markets must provide online tools that allow consumers to obtain real-time, personalized estimates of their cost-sharing responsibilities for covered services. This requirement applies to both in-network and out-of-network providers.
These price transparency measures have significant implications for RCM processes, as they necessitate the accurate and timely maintenance of pricing data, as well as the development of tools and processes to effectively communicate this information to patients and payers.
Interoperability and Patient Access to Health Information
The 21st Century Cures Act, enacted in 2016, aimed to improve data interoperability and patient access to health information.
The Office of the National Coordinator for Health Information Technology (ONC) has issued regulations to support the implementation of this act, including:
Information Blocking Prohibition
As of April 5, 2021, healthcare providers, health IT developers, and health information networks are prohibited from engaging in practices that constitute “information blocking,” which involves interfering with the access, exchange, or use of electronic health information (EHI). This requirement has implications for RCM processes that involve the exchange of patient data, such as eligibility verification and claim submission.
Application Programming Interface (API) Certification
The ONC has established certification criteria for health IT modules that require the use of standardized APIs for accessing and exchanging EHI. These APIs facilitate the seamless exchange of patient data between providers, payers, and other stakeholders involved in the revenue cycle.
Compliance with these interoperability and patient access requirements is essential for efficient RCM processes, as they enable the secure and timely exchange of patient data, which is critical for activities such as eligibility verification, prior authorization, and claim submission.
Coding and Documentation Updates
The healthcare industry regularly updates coding and documentation standards to reflect changes in medical practices, technologies, and regulatory requirements. These updates have direct implications for RCM processes, as accurate coding and documentation are crucial for proper reimbursement.
Some recent updates include:
ICD-10-CM/PCS Code Updates
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) codes are updated annually to reflect changes in medical terminology and procedures. RCM teams must ensure that their coding staff is trained on these updates and that their systems are configured to accommodate the new codes.
CPT and HCPCS Code Updates
The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, used for billing and reimbursement purposes, are also updated regularly. RCM teams must stay informed about these changes and ensure that their systems and processes are updated accordingly.
Documentation Requirements
Payers and regulatory bodies often update their documentation requirements for specific services or conditions. RCM teams must ensure that providers are aware of these changes and that their documentation practices comply with the latest guidelines to avoid denials or delays in reimbursement.
Telehealth and Virtual Care Regulations
The COVID-19 pandemic accelerated the adoption of telehealth and virtual care services, prompting regulatory changes to facilitate access to these services and ensure appropriate reimbursement.
Some notable regulatory developments in this area include:
Expansion of Covered Telehealth Services
In response to the public health emergency, CMS and many private payers expanded the list of covered telehealth services and relaxed certain requirements, such as the originating site and geographic restrictions. RCM teams must stay updated on the latest coverage policies and ensure that their billing practices align with these changes.
Licensure and Credentialing Requirements
Some states have implemented temporary or permanent changes to licensure and credentialing requirements for providers delivering telehealth services across state lines. RCM teams must ensure that their providers are compliant with these requirements and that their billing practices reflect the appropriate provider credentials.
Privacy and Security Considerations
The increased use of telehealth and virtual care services has heightened concerns around patient privacy and data security. RCM teams must ensure that their processes and systems comply with relevant regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws.
Value-Based Care and Alternative Payment Models
The healthcare industry is shifting towards value-based care models, which aim to improve patient outcomes and reduce overall costs. This shift has led to the introduction of alternative payment models (APMs), such as bundled payments, accountable care organizations (ACOs), and patient-centered medical homes (PCMHs).
These models have significant implications for RCM processes, including:
Risk-Based Contracting
Many APMs involve risk-based contracting, where providers assume financial risk for the cost and quality of care provided to a defined patient population. RCM teams must develop processes and systems to track and manage these risk-based arrangements, including monitoring quality metrics and reconciling shared savings or losses.
Data Analytics and Population Health Management
Value-based care models require providers to focus on population health management, which involves analyzing data to identify high-risk patients and implementing proactive interventions to improve outcomes and reduce costs. RCM teams must collaborate with clinical teams to ensure that data capture and reporting processes support these initiatives.
Care Coordination and Care Management
APMs often emphasize care coordination and care management activities, which may involve additional documentation and coding requirements. RCM teams must ensure that these activities are properly documented and coded to support appropriate reimbursement under the respective payment model
Regulatory Compliance and Audits
As the healthcare regulatory landscape becomes increasingly complex, regulatory compliance and audits have become a significant focus for RCM teams.
Some key considerations in this area include:
Compliance Programs
Healthcare organizations are expected to have effective compliance programs in place to ensure adherence to regulations and prevent fraud, waste, and abuse. RCM teams play a crucial role in these programs by implementing policies and procedures that promote ethical billing practices and maintain the integrity of the revenue cycle.
Audits and Investigations
Healthcare providers may be subject to audits and investigations by various entities, including the Office of Inspector General (OIG), the Department of Justice (DOJ), and third-party payers. RCM teams must be prepared to provide accurate and complete documentation to support their billing practices and respond appropriately to audit requests or investigations.
False Claims Act and Anti-Kickback Statute
The False Claims Act and Anti-Kickback Statute are two key laws that prohibit fraudulent billing practices and improper financial relationships in the healthcare industry. RCM teams must ensure that their processes and policies comply with these laws to avoid potential penalties and legal consequences.
Cybersecurity and Data Privacy
With the increasing digitization of healthcare data and the growing threat of cyber attacks, cybersecurity and data privacy have become critical concerns for RCM processes.
Some key regulatory developments in this area include:
HIPAA Security and Privacy Rules
The HIPAA Security and Privacy Rules establish national standards for protecting the confidentiality, integrity, and availability of electronic protected health information (ePHI). RCM teams must ensure that their systems and processes comply with these rules, including implementing appropriate technical, physical, and administrative safeguards.
State Data Privacy Laws
In addition to federal regulations, many states have enacted their own data privacy laws, some of which may have more stringent requirements than HIPAA. RCM teams must stay informed about these state-specific laws and ensure that their processes and policies align with the applicable requirements.
Cybersecurity Frameworks and Best Practices
Various organizations, such as the National Institute of Standards and Technology (NIST) and the Health Information Trust Alliance (HITRUST), have developed cybersecurity frameworks and best practices for the healthcare industry. RCM teams should consider adopting these frameworks and implementing appropriate security controls to protect sensitive data and prevent cyber threats.
Health Equity and Non-Discrimination Regulations
The healthcare industry is placing increasing emphasis on promoting health equity and addressing disparities in access to care and health outcomes.
Several regulatory initiatives have been implemented to support these goals, including:
Section 1557 of the Affordable Care Act
Section 1557 prohibits discrimination in healthcare programs and activities receiving federal funding on the basis of race, color, national origin, sex, age, or disability. RCM teams must ensure that their processes and policies are non-discriminatory and provide equal access to services and resources.
Language Access and Cultural Competency
Regulations and guidance from the Department of Health and Human Services (HHS) and other agencies emphasize the importance of providing language assistance services and culturally competent care. RCM teams should consider implementing processes and training to support these initiatives, such as interpreter services and culturally sensitive communication practices.
Data Collection and Reporting
Some regulatory bodies and accreditation organizations require healthcare providers to collect and report data on patient demographics, social determinants of health, and health disparities. RCM teams may be involved in these data collection and reporting activities, as they often have access to relevant patient information.
Environmental Sustainability and Green Initiatives
As concerns about climate change and environmental sustainability continue to grow, the healthcare industry is increasingly focused on reducing its environmental impact.
Several regulatory initiatives and voluntary programs have been introduced to support these efforts, including:
Energy and Water Conservation Regulations
Various federal and state regulations aim to promote energy and water conservation in healthcare facilities, such as the Energy Policy Act of 2005 and the Energy Independence and Security Act of 2007. RCM teams should be aware of these regulations and collaborate with facility management teams to ensure compliance.
Waste Management and Recycling Programs
Healthcare facilities generate significant amounts of waste, including regulated medical waste and hazardous materials. Regulations and guidance from agencies such as the Environmental Protection Agency (EPA) and state environmental agencies dictate proper waste management and recycling practices. RCM teams should ensure that their processes align with these requirements and support facility-wide waste reduction initiatives.
Green Building Standards and Certifications
Organizations like the U.S. Green Building Council (USGBC) and the Green Guide for Health Care (GGHC) have established standards and certifications for sustainable healthcare facility design, construction, and operations. While not directly impacting RCM processes, these initiatives may influence organizational priorities and resource allocation, which could indirectly affect RCM teams.
Summary
The healthcare regulatory landscape is constantly evolving, and staying informed about the latest changes is crucial for successful Revenue Cycle Management (RCM). The regulatory updates discussed in this article cover a wide range of areas, including patient protections, price transparency, interoperability, coding and documentation, telehealth, value-based care, compliance, cybersecurity, health equity, and environmental sustainability.
Navigating these regulatory changes requires a collaborative effort from various stakeholders within healthcare organizations, including RCM teams, clinical staff, compliance officers, IT professionals, and leadership. RCM teams play a pivotal role in ensuring that processes and systems align with regulatory requirements, promoting accurate and ethical billing practices, and supporting organizational initiatives aimed at improving patient care, reducing costs, and promoting sustainability.
By staying informed, implementing effective policies and procedures, and fostering a culture of continuous improvement, healthcare organizations can successfully adapt to the ever-changing regulatory landscape and maintain the integrity of their revenue cycle operations.
