REVENUE CYCLE MANAGEMENT CHALLENGES FOR 2024
BY ED MARASCO, MPM, CMTE, EMT-P (RET)*
The new year has been filled with strong headwinds already for prehospital care medical revenue cycle management (RCM), but the community continues to push forward. As the 2023 holiday season was in full swing, there were some challenges projected ahead; however, there was also a great deal of optimism for the new year.
NO SURPRISES ACT
Late in 2023, health care providers got some welcome relief from the Independent Dispute Resolution (IDR) moratorium associated with the TMA Lawsuit decision. In the last half of 2023, this had a particularly negative impact on air medical services providers who suffered the long period of time with access to the IDR process. The team here at QMC worked hard on the advocacy front to get the IDR process activated once again. In concert with the efforts to get the process online again, the QMC operations team was also working to prepare and stage the release of all the claims (from August 2023 forward) that were on hold as a part of the moratorium. Once the process was activated again, RCM entities had mere WEEKS to submit MONTHS worth of claims through the IDR portal. The QMC team has applied extraordinary effort to process the backlog created by the folks in DC.
As positive as it was to have the IDR portal open again, the process presented great challenges in the first quarter of 2024. The backlog created delays with determinations by the IDR entities, more roadblocks from Health Plans and complications associated with a ruling that the NSA Cooling Off Period applies to the TMA Hold claims . . . in other words, claims that have been on hold since August of 2023 were now being placed on hold AGAIN in March of 2024 because of IDR determinations that were rendered in March of 2024. In addition, Providers continue to wait for payments from Health Plans well after the 30-day deadline imposed by the NSA.
VETERANS ADMINISTRATION AMBULANCE PAYMENT REFORM
At the turn of the new year, the community banded together to fight for relief from the proposed cuts to ambulance reimbursement by the Veterans Administration (VA). The proposed change, reducing from charge-based payments to the Medicare Fee Schedule, would have a devastating impact on BOTH air and ground ambulance providers. This change would have resulted in a tremendous financial insult for ambulance providers, especially those serving our nation’s Veterans, and resulted in another challenge to cash flow for the organizations that are a key element of the health care safety net. The change is on hold until early 2025 and there is bipartisan, bicameral legislation under consideration that would provide a long-term solution for all parties.
CHANGE HEALTHCARE CYBERATTACK
The Cyber Attack on Change Healthcare interrupted many mission-critical systems across the health care landscape. Reports indicate that Change is involved in more than 16 billion health care related transactions per year. This includes eligibility checks and coverage verification, prior authorization requests, pharmacy integration and prescription transmittal, payment processing and documentation, as well as exchanging clinical records. The attack unfolded around the 21st of February and all systems are not expected to be back online until late March. Even after the Change systems come back online, there will be a tremendous challenge in testing, verifying, and cleaning up the backlog. The impact of this incident is expected to last throughout the end of 2024 and beyond. American Hospital Association President and CEO, Rick Pollack called the cyber-attack “the most significant and consequential” incident of its kind involving the health care sector, in history.
THE ROAD AHEAD
All these challenges, along with the many operational challenges facing the prehospital care community, highlight a sobering reality for providers of emergency medical services and prehospital care. The expense side has been on a steady upward trend since before the pandemic. Staffing challenges, new technology, supply chain shortages, and the cost of drugs will continue to put pressure on the cost side of the equation. The aforementioned reimbursement challenges and the ongoing lack of a permanent, stable funding stream will continue to plague the revenue side of the equation. We have reached an inflection point with respect to the financial underpinnings of our community. Now, more than ever, leadership must have a focused, benchmark driven, and creative approach to financial management of prehospital organizations.
*Ed Marasco is QMC’s Vice-President of Business Development and a veteran healthcare provider and administrator with over 40 years of experience in emergency medical services, reimbursement, and consulting.
