NAHRI Quarterly Call: Revenue integrity functions and No Surprises Act

NAHRI members caught up with association updates, news, and more on the November 16 NAHRI members-only Quarterly Call.

The call kicked off with NAHRI Director Nicole Votta discussing the latest NAHRI news.

The 2022 Revenue Integrity Symposium (RIS) will be held at the Hilton Phoenix Resort at the Peak in Phoenix, Arizona, September 19–20. As we reconnect, RIS provides crucial opportunities to engage with like-minded peers across the healthcare spectrum. The event will feature the top-level educational sessions, industry-leading experts, and networking opportunities attendees have come to expect from RIS.

NAHRI is also seeking speakers for 2022 RIS. We’re looking for speakers to present on all aspects of revenue integrity, Medicare compliance, and revenue cycle, including, but not limited to, the following:

• Highlights of IPPS and OPPS updates
• Improving a revenue integrity program using analytics, metrics, and key performance indicators
• Maintaining an up-to-date and compliant chargemaster and setting policies for charging for procedures and supplies
• Best practices for reducing payer denials using targeted data analytics
• Current payer audit targets and strategies to protect revenue
• Strategies for designing and implementing a revenue integrity program, developing workflows, setting goals, and staffing
• Efficiently addressing NCCI edits and MUEs
• Enhancing your revenue integrity career through professional development and leadership skills
• Understanding the impact of patient status and payer regulations
• Developing strategies for accurately documenting, coding, and billing patient encounters and stays

If you don’t see your hot topic listed here, please contact NAHRI and share what expertise you can bring to the podium. Original ideas not included above are welcome. For more information on applying to speak at RIS, go here.

NAHRI is also offering two virtual conferences in 2022.

Mastering Utilization Review: A NAHRI Virtual Event will be held virtually March 8–9. This event is your chance to brush up on the intersection of utilization review (UR) and revenue integrity and take a deeper dive into hot topics including inpatient-only list compliance, Part A to B rebilling, Medicare’s rules for observation services, Medicare Advantage and the 2-midnight rule, and more.

The Critical Access Hospital and Rural Health Clinics Reimbursement Virtual Symposium, to be held virtually April 12–13, will get you up to date on the latest revenue integrity strategies and solutions for these facilities. The event will give CAH and RHC teams the chance to learn from experts and brainstorm with their peers. Expert speakers will share tips for managing Medicare policies, optimize coding and documentation, and ensuring complete and compliant revenue.

Revenue integrity functions

Next, NAHRI Advisory Board members Sarah L. Goodman, MBA, CHCAF, COC, CHRI, CCP, FCS, and Kay Larsen, CHRI, CRCR, talked about applying one of NAHRI’s more popular resources, Core Functions of Revenue Integrity, Second Edition, to everyday revenue integrity practices. Authored by current and former NAHRI Advisory Board member and recently updated for 2021, the book examines each piece of revenue integrity through the lens of 10 core functions.

“All of us in the revenue integrity realm have certain roles,” Goodman said. “We may focus [on] charge capture work. Maybe your focus is denials or maybe you are a coder. There are a lot of different aspects to the whole revenue integrity and revenue cycle process and this book does give a review of that.”

Goodman and Larsen wrapped up their discussion with some revenue integrity housekeeping tips for the end of the year. Understanding the ins and outs of the chargemaster, charge structure, and the various rules and regulations that apply is a critical part of managing annual updates, they agreed. Consider how charges are structured behind the scenes, how they’re entered, and how staff enter charges. If those aspects are overlooked, it’s possible to have a completely up-to-date chargemaster but still encounter easily avoidable claims and billing issues, Goodman said.

No Surprises Act

NAHRI Advisory Board members Ronald Hirsch, MD, FACP, CHCQM, CHRI, and Caroline Znaniec, MBA, MS-HCA, closed out the program with a look at the requirements and application of the provisions of the No Surprises Act.

The No Surprises Act will limit patients’ out-of-pocket costs at in-network levels and prohibit surprise billing or balance billing. The act and the regulations take effect for providers and facilities on January 1, 2022. Key requirements of the act include:

• Covered services
• Patient estimates
• Minimum payment
• Notice and consent
• Dispute resolution

Although the dispute resolution process between providers and payers has been a hot topic, operationalizing the patient estimates, or good faith estimates (GFE) will be particularly complex, according to Hirsch and Znaniec. They shared tools and scenarios to demonstrate how to generate GFEs for insured and uninsured patients.

Uninsured or self-pay patients may also enter into a dispute resolution process, Znaniec said. These patients may initiate the process if their actual bill is more than $400 in excess of the GFE. That threshold could easily be crossed if an unexpected finding during an exam or procedure required additional, medically necessary services.

“I think a lot of people are going to fumble on this, even on the payer side, come January 1 until we get more clarification,” she said.

A recording of the November Quarterly Call is available for NAHRI members. Listening to or presenting on Quarterly Calls awards one CHRI CEU. Register now for our 2022 series of calls. If you’d like to present on an upcoming call, please contact NAHRI at nahri@hcpro.com.