NAHRI’s third quarterly call offers detailed analysis of major regulatory changes

Wednesday, August 8, 2018

NAHRI members tuned in for expert revenue integrity advice and analysis during our third members-only quarterly call on July 31. NAHRI Advisory Board members dug into the details of the Medicare Physician Fee Schedule (MPFS) and the Outpatient Prospective Payment System (OPPS) proposed rules and 42 CFR Part 2.

NAHRI Associate Director Jaclyn Fitzgerald opened the call with an update on the newest NAHRI benefits and initiatives, including the Revenue Integrity Symposium, which will be held October 16-17 at The Wigwam Resort outside of Phoenix in Litchfield Park, Arizona. The Revenue Integrity Symposium is NAHRI’s premier event for revenue integrity and revenue cycle networking and education, offering you the opportunity to engage with NAHRI Advisory Board Members, share operational strategies with peers, and learn cutting-edge regulatory information that will arm you with the tools you need to take 2019 by storm. As a valued NAHRI member, you will save an additional $100 off the cost of admission—that’s in addition to our early bird discount of $100, which ends August 17. For more information including a full agenda and more details on member and group pricing, click here.

Next up on the agenda was a special announcement about NAHRI’s Certified in Healthcare Revenue Integrity (CHRI) credential. The credential will provide a trusted baseline of competency for revenue integrity professionals and is currently scheduled to go live in the fall. Click here to sign up to receive updates on the development of the CHRI and be among the first to have the opportunity to sit for the credential.

After the announcements, four NAHRI Advisory Board members offered in-depth insight and tips on several major regulatory concerns.

  1. Compliance with 42 CFR Part 2 can be a major stumbling block for organizations. Missteps can lead to serious penalties, but challenges abound and operationalizing the requirements can be complex. Donna Schneider, RN, MBA, CPHQ, CPC-P, CHC, CPCO, CHPC, vice president of corporate compliance and internal audit for Lifespan in Providence, Rhode Island, examined some of the challenges and provided a scenario for compliance using her organization’s experience as a case study. Organizations must first determine whether they fall under 42 CFR Part 2, which requires privacy and security protections for substance use disorder (SUD) patient information that are stricter than and separate from HIPAA, she said. Then, establish a system to ensure compliance. “The key to this is to make sure that you have an interdisciplinary approach to implementation and ensure patient  consent prior to the disclosure of identity, diagnosis, prognosis, or treatment related to SUD,” Schneider said. Organizations can use features in the EHR system to set additional privacy protections for SUD information and to allow specific role-based access.
  2. CMS is proposing major changes in the 2019 MPFS and the 2019 OPPS proposed rules. John D. Settlemyer, MBA, MHA, CPC, assistant vice president, revenue cycle, with Atrium Health in Charlotte, North Carolina, and Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc., in Spicer, Minnesota, analyzed some of the major proposed changes and their potential impact on revenue integrity. In the OPPS proposed rule, CMS outlines major changes to reimbursement for services provided at excepted, or grandfathered, provider-based departments. The agency is proposing to extend the 340B drug program payment reductions to non-excepted provider-based departments. “I don’t think it was a really big surprise to us to see that proposal. I guess the good news here is that they did not propose any further reductions to the ASP minus 22.5%,” Settlemyer said. In addition, the agency is proposing to reduce the payment rate for code G0463 to 40% of the OPPS rate when it is provided at an excepted off-campus provider-based department. Settlemyer and Shah encouraged listeners to read the proposal, analyze how it might impact their organization, and submit feedback to CMS. “I think to defeat this proposal it is imperative for providers to tell CMS through the comments process that all visit codes are not created equal so to assume they are is like apples and oranges,” Shah said. “In other words, the outpatient clinic visit G0463 code reported by hospitals is not the same as what CMS might think of as an E/M visit in the physician office setting.” Additionally, CMS seems to assume that every G0463 is accompanied by a physician visit code which is also not true, Shah added. CMS is proposing several major changes with far-reaching implications in the MPFS proposed rule. Among the most notable proposed changes are sweeping overhauls of the documentation guidelines and payments rates for E/M visit codes. CMS acknowledges that these are significant changes and specifically requests feedback on them. “They also want to know if some of these proposals would create unintended consequences such as fraud and abuse situations and they also talk about how they would have to release quite a bit of subregulatory guidance to facilitate implementation,” Shah said. That raises the question of whether everyone could even be ready for implementation of all these changes by January 1, 2019, she noted.
  3. Revenue integrity professionals are ideally placed to analyze the impact of proposed regulatory changes and can provide valuable feedback to CMS by submitting comments. Terri Rinker, MT (ASCP), MHA, revenue cycle director at Community Hospital Anderson in Anderson, Indiana, demonstrated how to formulate and submit an effective comment on a proposed rule. Rinker walked listeners through locating proposed rules on and provided tips for navigating documents that can number hundreds of pages. She recommended starting with the table of contents and the executive summary to identify specific proposals that are of interest to you. Then, navigate to that page and read the entire section. “If there’s something you’re interested in or something you’re knowledgeable about, that’s what you need to comment on. Don’t be afraid to share what your experience is, because CMS does not have the knowledge that you have being out in the trenches,” Rinker said. “Make sure you read everything that CMS is saying so that your comment is complete.” However, she added, it’s not necessary to comment on the entire rule. Focus on your areas of expertise to provide considered, well-reasoned feedback.

NAHRI members can download a recording of the July 31 call and the presentation slides on the Resources page of the NAHRI website and are encouraged to register for the next quarterly call scheduled for Tuesday, October 30 at 1 p.m. Eastern. If you’re a NAHRI member and are interested in presenting on an upcoming NAHRI members-only call, please contact Associate Director Jaclyn Fitzgerald at