The Centers for Medicare & Medicaid Services (CMS) published a final rule February 11, 2016 that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable. A separate final rule was published in the May 23, 2014 Federal Register (79 FR 29844) that addresses Medicare Parts C and D overpayments. Summary The requirements in this rule are meant to support compliance with applicable statutes, promote the furnishing of high quality care, and to protect the Medicare Trust Funds against improper payments, including fraudulent payment. This rule clarifies requirements for the reporting and returning of self-identified overpayments. Health care providers and suppliers have been and will remain subject to the statutory requirements found in section 1128J(d) of the Social Security Act (the Act) and could face potential False Claims Act (FCA) liability, Civil Monetary Penalties Law (CMPL) liability, and exclusion from federal health care programs for failure to report and return an overpayment. Health care providers and suppliers will also continue to be required to comply with current CMS procedures when we, or our contractors, determine an overpayment exists and issue a demand letter. Background Section 6402(a) of the Affordable Care Act established a new section 1128J(d) of the Act. Section 1128J(d)(1) of the Act requires a person who has received an overpayment to report and return the overpayment to the Secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and to notify the Secretary, state, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment. Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of: (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable. Section 1128J(d)(3) of the Act specifies that any overpayment retained by a person after the deadline for reporting and returning an overpayment is an obligation (as defined in 31 U.S.C. 3729(b)(3)) for purposes of 31 U.S.C. 3729. In the February 16, 2012 Federal Register (77 FR 9179), CMS published a proposed rule to implement the provisions of section 1128J(d) of the Act for Medicare Parts A and B providers and suppliers. Major Provisions The major provisions of this final rule include clarifications around: the meaning of overpayment identification; the required lookback period for overpayment identification; and the methods available for reporting and returning identified overpayments to CMS. Meaning of “Identification” Section 1128J(d) of the Act provides that an overpayment must be reported and returned by the later of: (i) the date which is 60 days after the date on which the overpayment was identified; or (ii) the date any corresponding cost report is due, if applicable. This final rule states that a person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment. Creating this standard for identification provides needed clarity and consistency for health care providers and suppliers regarding the actions they need to take to comply with requirements for reporting and returning of self-identified overpayments. Lookback Period Under this final rule, overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received. Specifying the length and other parameters of the look back period provides additional clarity for providers and suppliers who have identified an overpayment that is covered by the provisions of 1128J(d). How to Report and Return Overpayments This final rule provides that providers and suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments. This approach for returning overpayments provides an array of familiar options from which providers and suppliers can select. This rule also provides that if a health care provider or supplier has reported a self-identified overpayment to either the Self-Referral Disclosure Protocol managed by CMS or the Self-Disclosure Protocol managed by the Office of the Inspector General (OIG), the provider or supplier is considered to be in compliance with the provisions of this rule as long as they are actively engaged in the respective protocol. View the final rule in the Federal Register here: https://www.gpo.gov/fdsys/pkg/FR-2016-02-12/pdf/2016-02789.pdf

Experian Health is pleased to announce that its Patient Estimates solution has joined the athenahealth® Marketplace, also known as  the More Disruption Please (MDP) program. Experian Health has participated in this program since the launch of the marketplace in 2013 (starting with our Contract Management offerings) and has worked with athenahealth to integrate its industry-leading capabilities into the organization’s growing network of more than 73,000 healthcare providers. Learn more about Experian Health’s Patient Estimates solution. Read the press release To learn more about athenahealth’s MDP program and partnership opportunities, please visit https://www.athenahealth.com/disruption.

Experian Health is pleased to announce that we went live with Patient Estimates at St. Clair Hospital located in Pittsburgh, PA on February 22, 2016. A true representation of vendor and hospital collaboration and commitment, the Patient Estimates cost transparency tool gives St. Clair a competitive edge as the first hospital in its region to offer patients cost estimates in advance. Patient Estimates is not a list of charges, but an interactive and user-friendly tool that provides information that is highly specific to the individual. Estimates are designed to determine, in advance, each patient’s out-of-pocket costs (deductibles, co-pays and co-insurance) for services at St. Clair based upon his/her insurance coverage. The estimates also incorporate St. Clair’s discounts for payment on the date of service and for those without insurance. The estimates remain in the system and can be recalled for future reference. Patient Estimates is simple to use and is conveniently available 24/7 at www.stclair.org. On the home page, patients will select the “Financial Tools” option, then click on Patient Estimates. They will then enter their health insurance information before choosing one of the 100 listed clinical services (e.g., a procedure, treatment or diagnostic test) from the drop-down menu. The tool then provides a customized estimate of their out-of-pocket expenses. Patient Estimates is designed to help insured and uninsured patients get clear, real-time, easy-to-understand cost estimates for St. Clair’s services so patients can make informed decisions about their care. Below are some of the press mentions of St. Clair Hospital's implementation of Patient Estimates: Pittsburgh TRIBLIVE https://bit.ly/1oxlKna Pittsburgh Post-Gazette: https://bit.ly/219dqfd Pittsburgh Business Times: https://bit.ly/1QWfqNa

The title of Best in KLAS is a highly coveted recognition of outstanding efforts to help healthcare professionals deliver better patient care. It is reserved for vendor solutions that lead the software and services market segments with the broadest operational and clinical impact on healthcare organizations. ~KLAS Enterprises LLC Last month, Experian Health’s eCare NEXT® platform was awarded the highest score in the Patient Access category of the 2015/2016 Best in KLAS: Software & Services report. This is the 5th straight year Experian Health has received the highest ranking in the patient access category—3 years as Category Leader in Patient Access – Eligibility Checking and now 2 years Best in KLAS in the broader Patient Access category. The KLAS award confirms our strong commitment to continually provide advanced technology and revenue cycle products for our clients, and consistently develop enhancements and new solutions with them. We are proud of the collaboration between our progressive clients and our dedicated employees to ensure clients provide the best patient care experience, and achieve payment certainty for every patient. It’s a great honor that our clients continue to hold Experian Health’s solutions in such high regard that we have been recognized consistently by KLAS year after year. View Press Release View full list of Best in KLAS winners and Category Leaders

Episode management, particularly the 30-90 days post-discharge, is incredibly important for all types of healthcare entities seeking to succeed under value-based reimbursement. Millions of dollars in revenue, shared savings, and bundled payment contracts are at-risk when hospitals, ACOs, bundled payment conveners, and others don’t have visibility into their patient’s care after hospital discharge. Leading health care organizations are realizing the solution is not simply to hire an army of care managers, but rather, to supplement a care management team with focused automation to double or triple their productivity by sharing workflow and care management with the patient’s community providers, including independent MD offices, skilled nursing facilities (SNFs), home health agencies (HHAs), and others. Having the right care solutions in place is critical to ensuring successful episode management. View our on demand webinar to learn care coordination best practices and find out how Experian Health’s innovative solutions can help your organization: Reduce readmissions and manage episode/post-acute costs Maximize Medicare reimbursement, minimize Medicare penalties and, hopefully, earn bonuses Profit at and contract for bundled payments Maximize commercial reimbursement Improve outcomes and lower costs for greater fee for value (FFV) in the future Learn how Experian Health can help you success in the new FFV environment. Access our on demand Episode Management webinar.

In the 1930s, Ovaltine offered listeners of the Little Orphan Annie radio program a membership badge with a decoder ring that allowed listeners to replace numbers with letters and figure out secret messages – which usually urged them to drink Ovaltine.. Fast forward to 2015, and a decoder ring can be bought online for under $20. Unfortunately, these trinkets aren’t sophisticated enough to help practices and hospitals decipher reimbursement contracts and identify underpayments. Providers today require robust analytics and automated workflows, coupled with a level of support that goes far beyond an instruction manual to include continual updates to contract terms by skilled contract analysts. According to the American Hospital Association, combined Medicare and Medicaid underpayments were $51 billion in 2013. Private payers further contribute to underpayments, totaling a hefty financial gap for providers, regardless of care setting. It is imperative that providers across hospitals and medical groups take proactive measures to ensure they are paid fully and fairly for the care and services delivered. Incorporating automated solutions enables providers to fully decode the hidden “catches” in contracts while recovering underpayments. Understand how proposed contracts with payers affect your revenues When a payer assures you that proposed contract changes will benefit your organization, are you skeptical? Using contract analysis and modeling, you can accurately predict how a change in any of the hundreds of variables in third-party contracts will affect reimbursement for your precise mix of services. Not only can contract analysis let you see the overall impact of an individual contract, it also lets you precisely model revenues so you can see the gains or losses for each individual specialty, provider or service. By assessing which factors have the greatest impact on your reimbursement, you can refine your bargaining strategy to negotiate better-performing contracts.  Verify the accuracy of payment received from third-party payers Ensuring your contracts are as advantageous as possible is just half the battle; you still have to confirm that payments follow the guidelines of the contract. Complicating this process is the move to new reimbursement structures that bundle payments or base them on value rather than services. Verifying payment accuracy can easily bog down your team–unless you put the benefits of automation to work for you. Contract management and analysis solutions streamline workflow by auditing claims so you spend time only on those that require intervention. Through data-driven insight, you can conduct contract-based appeals and recover lost revenue. Together, these solutions assist in reviewing and modeling contracts, and then accurately identifying, appealing and recovering underpayments. With the ability to value the claims you file and evaluate overall contract performance, you decode the information locked away in data. All without a decoder ring. Don’t miss our upcoming webinar, "Overcoming the Three Ps: Payers Who Pay Poorly” Featured Speakers: Kristen Prenger, Director of Managed Care, Lake Regional Health System Rebecca Charo, Product Director, Experian Health Date: Thursday, May 21, 2015 Time: 11 a.m. PT/1 p.m. CT/2 p.m. ET Register now!

Significant changes in health insurance coverage are delivering a good and bad news report for providers. The good news is the continuing decline in the number of uninsured Americans. As of January 2015, the current uninsured rate is at an historic low of 12.9%. Much of this decrease can be attributed to the Affordable Care Act (ACA), with 7.1 million people enrolled in a plan on the federal marketplace, as well as an estimated 2.4 million people who obtained insurance through state exchanges. Add to that young adults staying on their parents’ plans (3 million), another 10 million people who are covered through Medicaid and Children’s Health Insurance Plan (CHIP), job-based coverage and plans outside of the marketplace, and the picture should seem rosy. However, the bad news comes when these newly insured people begin using their benefits and are faced with deductibles, coinsurance and copays. Providers are seeing more patients with insurance coverage who find it challenging to handle these additional out-of-pocket expenses. Compounding the challenge is the increase in high-deductible health plans (HDHP) and/or health savings accounts. The number of people with HDHPs has risen from 19.2 percent in 2008 to 33.4 percent in 2014, as reported by the Centers for Disease Control and Prevention. Tackling the problem Healthcare providers not only have a mandate to provide care, most also are deeply committed to providing charity care when it is needed. However, in order to remain solvent, providers must protect their financial well-being by actively seeking reimbursement and payment when it is available and applicable. But, how can organizations strike the right balance? As a first step, having a system in place for assessment, enrollment and case management will not only help you maximize reimbursement by enrolling self-pay patients in Medicaid or qualifying them for internal charity care, it can also be used to document your facility’s charitable services. Key components to a well-orchestrated charity program include:  Screen for financial assistance using the most up-to-date qualification guidelines for Medicaid and other financial aid and charity programs. Ensures patients who are eligible for charity care, Medicaid and other assistance programs receive needed financial support. Determine a patient’s propensity to pay, so that you can evaluate payment risk, identify the most appropriate collection route and initiate targeted financial counseling discussions. Organizations can then maximize reimbursement dollars from Medicaid and other financial assistance programs and reduce uncompensated care and bad debt write-offs. Verify patient identity to reduce fraud risk, claims denials and the rate of returned mail – expediting reimbursement. This process streamlines the financial assistance screening and enrollment process to increase staff productivity as well as patient satisfaction. Through these strategies, organizations can more effectively identify patients eligible for charity, combatting ongoing patient financial responsibility challenges – or the bad news – while still capitalizing on the good news of more patients receiving coverage. Learn more about charity care initiatives by registering for our upcoming webinar, “Financial Screening in the age of the Affordable Care Act,” on March 11, featuring Brandon Burnett discussing Kaiser Permanente’s experience and initiatives and Kim Berg from Experian Health.

As discussed in part one of this blog series, technology such as patient portals are changing the way physicians are interacting with patients and how those patients access their medical information. An article in USA Today quotes the American Academy of Family Physicians on usage: 41% of family practice physicians use portals for secure messaging Another 35% use them for patient education About one-third use them for prescribing medications and scheduling appointments While intuitively it might seem that online interactions would distance physicians and patients, the reverse is actually true. Researchers found that patients who had online access to their physicians and other healthcare professionals increased their use of in-person and telephone clinical services, according to a study published in The Journal of the American Medical Association. Increases in patient engagement can carry over into patient billing portals. Take Cincinnati Children’s Hospital Medical Center (CCHMC), for example. The organization decided to update its patient billing portal two years ago in the hopes that a better interface and more functionality would increase the number of families using the portal. With only a one-time notice in a paper statement, CCHMC saw adoption rates soar more than tenfold in the first year after implementing the new platform. CCHMC, which is consistently ranked in the nation’s top five children’s hospitals, also experienced an increase in collections of 10-15%, and a five-fold increase of online payments, up from $200,000/month to $1 million/month. The patient-friendly portal now has more than 22,000 families using its self-service functions. The portal gives users 24/7 online account management, along with the ability to schedule appointments, pay bills and access lab results. Families now have anytime, anywhere access to their account, an important benefit for busy families trying to cope with a sick child. In conjunction with the online portal modernization, CCHMC also gave its printed patient statements a facelift. Not only did patients find the previous multi-page statements confusing, it had become increasingly expensive and time consuming to make even minor information changes and updates. Altering something as simple as a phone number or office hours could cost thousands of dollars in custom programming fees. The adoption of a new patient statement solution has given CCHMC the ability to make statement changes in house, eliminating custom programming while also reducing mailing expenses. In the first year, CCHMC saved $70,000 on their monthly invoicing due to lower printing and mailing costs, reducing the statement size from two pages to one and receiving discounts on postage. With patient experience and engagement a top priority for providers, it’s critical to consider a similar approach that works for your organization—an approach that will help patients be more active participants in their health, as well as support your clinical and financial goals. CCHMC will discuss its experiences with patient engagement, administrative savings and lessons learned at our January 28 Webinar, “Improving the Patient Billing Experience Through Online Customer Self-Service.” Register now to attend.

Rudyard Kipling famously wrote, “Oh, East is East, and West is West, and never the twain shall meet.” That was once true of care delivery and medical payments; they were two separate departments encountered at different stages during a physician or hospital visit, and each was siloed to the activities of the other. Today, patients are avid participants in their care and are more engaged and concerned with where their healthcare dollars are spent. With that in mind, savvy providers are collaborating with patients not only on a clinical level, but also on the financial side to better navigate their options. This new approach gives patients the power to make informed financial decisions about their care, with discussions taking place prior to treatment, rather than after when an unexpected bill or lack of understanding around financial obligations can negatively impact a patient’s overall perception of their care and the organization itself. While it’s no surprise that patients are taking on greater financial responsibility for their healthcare costs due in large part to the rapid rise of high-deductible health plans, the statistics are overwhelming. In 2006, only 55 percent of covered workers had an annual deductible, which averaged $584. In 2014, according to the Kaiser Family Foundation, that deductible has more than doubled to an average of $1,217 for 80 percent of the covered workforce. When you consider that slightly over half of covered workers have an annual out-of-pocket maximum of $3,000 or more, that creates a gap that providers can’t ignore for the sake of their fiscal health, or that of their patients. At the heart of achieving better patient engagement on the financial side is accurate, real-time information. Advanced technology gives providers the ability to provide patients with a more comprehensive picture of financial information and to present them with financial options that fit their needs. Three key steps to achieving higher payments and better patient satisfaction include: 1)    Be proactive – Talking to patients prior to receiving care not only results in higher patient engagement and satisfaction, it also substantially increases the amount providers can expect to collect. For example, showing online full-disclosure of billing data builds trust among patients. 2)    Provide accurate estimates – Patients deserve the right to make informed decisions based upon the cost of care. For example, providers should be able to quickly – and easily – review expected costs and explain insurance coverage. Offering patients tools, such as the ability to request a real-time estimate online, gives them more control over the financial side of their healthcare. 3)    Offer choices – Payment plans designed in cooperation with patients, such as the ability to set up automatic payments, not only empowers them, it improves payments and reduces administration burdens. Implementing these initiatives creates a more informed patient, which leads to a positive care experience and eases financial stressors. Patients are able to make educated choices and, if necessary, structure a payment plan that meets their needs or identify potential financial assistance programs. Providers also see benefits, such as increased patient loyalty as well as an improved revenue cycle and decreased administrative burdens when it comes to collections and follow up. Mr. East, meet Ms. West. By integrating the clinical and financial sides of healthcare, patients are more engaged with their care, leading to better health for the patient and improved financial outcomes for providers.