CMS Releases No Surprises Act – Part II

October 22, 2021

Randi A Brantner, MBA-HA
Vice President of Analytics

On September 30, 2021, the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury released Part II of the “No Surprises Act” which was published in the Federal Register on October 7. The Act, which goes into effect on January 1, 2022, aims to protect patients from unexpected out of pocket costs resulting from surprise and balance billing.

Part II of the Act addresses plan coverage requirements, independent dispute resolution processes between the payers and providers, and details for how payers will determine patient cost-sharing responsibilities.

The Centers for Medicare & Medicaid Services (CMS) devotes a website to the No Surprises Act, Ending Surprise Medical Bills, which covers policies and resources, help with resolving payment disputes, and information on consumers rights and protections.

On September 31, CMS published a Fact Sheet, Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period. Previously, CMS published a Fact Sheet covering Part 1, Requirements Related to Surprise Billing; Part I Interim Final Rule with Comment Period, on July 1, 2021.

Pararev can help

An essential component of the “No Surprises Act” is the ability for the provider to deliver pricing transparency to the consumer. Meeting the challenges of pricing transparency demands a systematic approach grounded in empirical evidence and a capable staff implementing proven solutions. Pararev, a leader in accounts receivable recovery and resolution, can help you execute all steps necessary to comply with the transparency rule and improve patient satisfaction. To see how this solution would work for your hospital, click here to view a short demo.

Contact us today to learn more about how we can help your organization prepare for the pricing transparency requirement that is a critical component of the “No Surprises Act”.

Overcome the challenges of hospital pricing and revenue cycle management for improved revenue capture and better margins. Download our whitepaper to discover 3 ways to accelerate your financial transformation!

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Appropriate Use Compliance Deadline Delayed

October 20, 2021

Barbara Johnson, BSN, RN, CPC, FHFMA
Senior Revenue Cycle Consultant

In 2019, the Centers for Medicare & Medicaid Services (CMS) announced that calendar year 2020 would serve as a “test and educate” period during which providers billing for advanced imaging studies are required to report whether the ordering physician consulted a clinical decision support mechanism. The requirement to report the informational codes is currently in effect, but Medicare will not yet impose penalties for failure to report, or for incorrect reporting. (The requirement does not apply to Critical Access Hospitals). The Appropriate Use Compliance (AUC) program was authorized by the Protecting Access to Medicare Act of 2014 (PAMA) to promote the use of AUC and decrease the number of inappropriate advanced diagnostic imaging services provided to Medicare beneficiaries.

Ordering physicians (or clinical staff acting at the physician’s direction) will consult the AUC using a clinical decision support mechanism (CDSM). The CDSM is an interactive, electronic tool that is either stand-alone or integrated into an electronic health record (EHR). When queried, it provides a response indicating that the advanced diagnostic imaging service is appropriate, not appropriate, or not applicable for the patient. The AUC requirements apply to advanced diagnostic imaging services (CT, PET, MRI, and Nuclear Medicine) provided in physician offices, hospital outpatient departments (including emergency departments), ambulatory surgical centers, and independent diagnostic testing facilities.

Consulting CDSMs exceptions

CMS released an MLN Matters article in July 2019 that includes the imaging HCPCS codes, the G-codes for the CDSMs, and AUC modifiers. There are a few exceptions to the requirement to consult the CDSM, which are:

  • Emergencies
  • Inpatient advanced diagnostic imaging services
  • Ordering physician meets hardship exception
    • Hardship exceptions include:
      • Insufficient internet access
      • EHR or CDSM vendor issues
      • Extreme and uncontrollable circumstances

If an exception exists, the physician will include it with the order and the furnishing physician will report the corresponding modifier on the claim.

AUC Requirements

After the physician has consulted the CDSM and ordered the advanced diagnostic imaging service, the following data will be sent, with the order, to the provider completing the imaging service:

  • The CDSM consulted by the ordering physician.
  • Whether the service adhered to the applicable AUC, did not adhere to the applicable AUC, or whether no criteria in the CDSM were applicable to the patient’s clinical scenario.
  • The National Provider Identifier (NPI) of the ordering physician. CMS maintains a list of qualified CDSMs on its website at Clinical Decision Support Mechanisms | CMS.

The following list was posted on August 30, 2021:

Mechanism NameCode
eviCore healthcare’s Clinical Decision Support MechanismG1001
MedCurrent OrderWiseTMG1002
Medicalis Clinical Decision Support MechanismG1003
National Decision Support Company CareSelectTM*G1004
AIM Specialty Health ProviderPortal®*G1007
Cranberry Peak exCDSG1008
Sage Health Management Soluntions Inc RadWise®G1009
Stanson Health’s Stanson CDSG1010
AgileMD’s Clinical Decision Support MechanismG1012
EvidenceCare’s Imaging AdvisorG1013
InveniQA’s Semantic Answers in MedicineTMG1014
Reliant Medical Group SCSMG1015
Speed of Care CDSMG1016
HealthHelp’s Clinical Decision Support MechanismG1017
LogicNets AUC SolutionG1019
Curbside Clinical Augmented WorkflowG1020
E*HealthLine Clinical Decision Support MechanismG1021
Intermountain Clinical Decision Support MechanismG1022
Persivia Clinical Decision SupportG1023

New Advanced Diagnostic Imaging HCPCS Modifiers

Medicare also released eight new modifiers to be appended to the imaging HCPCS when an advanced diagnostic imaging is billed. The modifiers indicate the clinician’s use (or non-use) and compliance with a CDSM when ordering advanced diagnostic images.

Modifiers to be appended to Advanced Diagnostic Imaging HCPCS on Medicare Outpatient Claims

ModifierShort DescriptorLong Descriptor
MAEmer med cond susp/confirmOrdering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition
MBAUC hardship, insuf internetOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access
MCAUC hardship, vendor issuesOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
MDAUC hardship, extreme circOrdering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncomfortable circumstances
MEOrder adheres to AUCThe order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MFOrder does not adhere to AUCThe order for this service does not adhere to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional
MGAUC not applicable to orderThe order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
MHAUC consult not providedUnknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider
a data table in medical billing software

The excerpt below illustrates the mandatory reporting for a CT of the head billed to Medicare on a UB04:

AUC workflow requirements

The following is the workflow for meeting the AUC requirements:

  • The physician sees a Medicare beneficiary and plans to order an advanced diagnostic imaging service
  • The physician (or clinical staff under the direction of the physician) consults the AUC for the proposed advanced diagnostic imaging service through a CDSM. The CDSM can be integrated into the EHR or a separate portal
    • If a hardship exception exists, the physician will include it with the order
  • The CDSM will search for and present the AUC relevant to the patient’s condition
  • The CDSM response will indicate if the proposed advanced diagnostic imaging service:
    • adheres to the AUC, or
    • does not adhere to the AUC, or
    • if there is no applicable AUC
  • If it adheres to the AUC, the physician will proceed with the order
  • If it does not adhere, the physician must decide to order a different imaging service or proceed with the proposed service despite it not adhering to the AUC
  • The physician orders the advanced diagnostic imaging service and includes with the order:
    • the CDSM queried, and
    • the AUC response, and
    • the physician’s NPI
  • The rendering provider furnishes the imaging service to the patient
  • The rendering provider reports in the professional and institutional claims:
    • HCPCSG-code associated with the CDSM, and
    • The applicable AUC modifier, and
    • the ordering physician’s NPI

Analysis of ordering physician practices

The outcome of this program will be to analyze the ordering practices of the physicians and determine any outliers. PAMA calls for identification on an annual basis of no more than five percent of the total number of ordering physicians who are outliers. The use of two years of data is required for this analysis. Data collected during the education and testing period will not be used when identifying outliers. Outliers will be determined based on low adherence to applicable AUC or comparison to other ordering physicians. Physicians who are found to be outliers will be required to complete prior authorizations for advanced diagnostic imaging services.

The following clinical areas will be the focus of the analysis of outliers:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and non-traumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Compliance Assistance

Pararev can provide compliance assistance to help you navigate the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation.

Pararev is a revenue cycle solutions provider that offers price transparency, reimbursement, revenue integrity/coding, and compliance support. Comprised of seasoned professionals and equipped with a web-based cloud computing engine, the Pararev Data Editor (PDE), they analyze, identify, repair, and improve the revenue cycle processes to support Providers in achieving their financial goals.

Pararev is comprised of a team of coders, compliance experts, financial analysts, and IT professionals with extensive experience in focused disciplines to support the revenue cycle process. In fact, on average, our consultants have over 21 years of healthcare experience, allowing them to support clients with experience from the trenches. Pararev’s services range from a web-based revenue cycle tool to a comprehensive revenue integrity program complete with a chargemaster audit, pricing services, monthly department meetings, and ongoing pricing, coding, reimbursement, and compliance support.

Contact us to learn more about how we can help you navigate today’s healthcare compliance concerns including the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging regulation and more.

Zero-balance claims reviews represent a final safety net that can generate hundreds of millions of dollars for hospitals

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Primary & Secondary AR Recovery and Resolution

Revenue Capture

ParaRev pursues your aging, small-balance claims identified by your staff as problematic. If a claim has previously been worked internally, referring it to ParaRev’s dedicated, specialized teams can help ensure quicker cash conversion and a reduction of bad debt reserves.

Primary AR recovery and resolution

ParaRev helps ensure hospitals and health systems quicker cash conversions and a reduction of bad debt reserves through a team of dedicated specialists combined with intelligent automation, our proprietary, next generation technology. ParaRev supports your specific AR requirements by working claims based on your processes – both small and high-balance claims as well as highly-aged claims. Our flexibility and scalability allow us to work in partnership with your CBO to recover and resolve all outstanding insurance claims based on your balance and age criteria.

Improve your AR with our core competencies:

  • Provide a virtual extension to bolster your central billing office’s resources with a dedicated, knowledgeable and responsive team of experts who have specific experience with your payers
  • Integrate seamlessly with your systems and sits on the background for ease of working relationship
  • Decrease cycle time through transformative intelligent automation and advanced business process engineering expertise
  • Ensure all claims, no matter age or balance, are effectively worked to 100% resolution utilizing appropriate staffing
  • Prevent future AR issues through proactive denial management using root cause analytics to identify and address problems at the source
  • Ensure the security of your PHI with HITRUST CSF certification

Pre write-off (Secondary) AR recovery and resolution

Hospitals and health systems are realizing that the highly-aged claims they would have written off, present a potentially major, untapped revenue stream. Also known as secondary assigned accounts or second placement AR services, pre write-off insurance collections provide a critical safeguard to ensure no insurance payments legitimately due the hospital go uncollected, regardless of age. Through a team of dedicated specialists combined with intelligent automation– our proprietary, next generation technology, ParaRev can efficiently pursue these claims and maximize cash returns.

Benefits of enlisting a pre write-off recovery partner:

  • The establishment of an AR management process that offers a systematic approach to obtaining 100% claims resolution
  • A reduction in write-offs, a commensurate increase in cash flow and a decrease in bad debt reserves caused by aging accounts
  • The creation of incentives that push primary AR vendors to optimize their processes
  • Greater transparency to enable hospitals to evaluate performance across the entire revenue cycle
  • Let ParaRev focus on those claims that are approaching the end of the typical recovery cycle to help you collect more cash.

Spot/cleanup projects

Revenue Capture

ParaRev is available to assist you as relief valve in multiple scenarios:

  • EMR conversion projects—Assist with legacy platform to ensure staff has priority focus on new platform, or vice versa
  • Fiscal year-end projects—Assist with achieving aging and cash goals
  • Overall spot projects—ParaRev is available to assist for assorted project needs that are not necessarily ongoing in nature
  • Test trial projects—Let ParaRev prove ourselves with a one-time project to show you what we can do

As a vendor, our goal is to be flexible and assist our clients however needed. Our goal is to prove through our technology and experience that we can be a true partner for any healthcare provider.

Legacy system conversions

Revenue Capture

For hospitals and health systems, replacing or upgrading an electronic health record (EHR) is a major undertaking fraught with operational and financial risk. Whether you’re upgrading your legacy system or integrating an acquisition into your current system, it’s essential that you ensure the smooth transition of clinical information, accurate coding, demographic, and financial data to sustain billing operations.

Supporting a seamless conversion requires extensive planning and training, along with laser-like focus on the operations and features of the new platform. Yet too often, billing personnel are pulled in multiple directions as they scramble to master the complexities of the new system while trying to wind down aging accounts receivable (AR) tied to the legacy platform. Attempting to juggle these competing duties can produce the worst of both worlds: The volume of outgoing claims submitted through the new system falls, while unresolved accounts in the old platform pile up. Cash flow erodes as days in AR and denials increase. And if unanticipated problems or delays emerge during the EHR implementation, the financial problems can quickly snowball.

ParaRev can help

  • Let us help you mitigate these risks and preserve cash flow by handling the legacy accounts, allowing internal staff to concentrate solely on handling new system billing activities. By focusing just on the new system, in-house personnel can more quickly develop the skills and knowledge necessary to assemble and submit claims in an accurate and expeditious manner.
  • Do you have times where you have a backlog of old accounts? ParaRev can help you here, too by deploying a team of experts to help you clean up these episodic backlogs.
  • With ParaRev as your partner you can be assured that all aging denials are worked methodically and completely to resolution. That means cash can be collected on accounts that otherwise would likely have been written off.

Specialized payer resolution

Revenue Capture

ParaRev has experience handling all situations and all payers, and can take on any long-term or temporary AR projects you have in mind and will improve reimbursement, reduce denials, and decrease audits.

Our expertise ranges from:

  • Clinical denials (including prior authorization and medical necessity), handled by the expert RN staff of our utilization team
  • Coding and billing issues, resolved by our certified coders
  • Workers Comp/Personal Injury, handled by our specialized WC/PI team
  • COBs and patient denials
  • High- and low-balance account resolution
  • Aged problematic accounts and backlogs
  • Appeals
  • Corrected claims and rebills
  • Fiscal year-end collections

Targeted denial resolution

Revenue Capture

ParaRev has over 20 years of AR and denial management resolution experience.

  • Our system and our processes are what sets us apart from other AR firms.
  • Our system is an automated decision tree, driven by our clients’ desk procedures and years of experienced industry-leading solution best practices. This platform is driven off EDI analytics, which starts an FTE at the appropriate initial step to expedite resolution.
    • Once a person is set at the correct initial starting point, the system guides them step-by-step through the resolution process of that issue, forcing the correct action to be taken.
    • Through this system, any type of issue or process can be streamlined for maximum efficiency.
  • Our workflow system keeps track of what needs to be done and when. Keeping our reimbursement specialists focused on what they need to accomplish and providing management the visibility into items that need action. Our system automatically sets reminders and ensures accounts get the required actions completed prior to timely filing.
  • ParaRev creates custom workflows for our individual clients based on their processes and procedures; our workflows will mirror your workflows. ParaRev creates these workflows for all major denials/issues; they are built into our software, ensuring your policies and best practices are followed. By guiding our staff through the best next steps within our software, we can ensure the highest levels of performance.
  • We have found that dedicated reps are far more productive than pooled staff. Working with a specific client not only gives them the ability to learn the client’s business & payer contracts, they also learn their culture and become experts on your specific collecting process, as every client is different. Along with dedicated team members performing follow up, ParaRev provides dedicated managers, supervisors, and team leads to your account—available whenever you need their expertise or insight.
  • Problem identification and communication is key. All of the above processes provide us with a tremendous amount of information. This information is then analyzed and provided to our clients in the form of dashboards, monthly reports, and quarterly meetings, including recurring deep-dive analytic presentations from subject-matter experts that will uncover root causes driving AR issues.  This information often results in helping our client strategically improve their revenue cycle by identifying front-end, system/edit, and payor-related opportunities.  By partnering with ParaRev your operation typically will see improved collections and reduced aging on the subset of the accounts outsourced. This is due to our process and the fact that we would be applying more attention to a targeted area of accounts that may not have historically seen as much focus. Our goal is to be a relief valve and allow your internal staff to target the younger inventory in other areas that need attention.

Underpayment Recovery

Revenue Capture

ParaRev’s Underpayment Recovery service consists of Underpayment ParaRev’s STAT Revenue team applies nationwide revenue cycle expertise to recover underpayments from your payers. Our recommendations and trainings deliver customized and innovative solutions to your hospital. We enable your team to minimize future underpayment exposure, while recovering existing contractual underpayments to improve your bottom line. Our underpayment recovery service includes:

Underpayment Recovery

Behind robust contract management systems, strong front line PFS staff, and third party vendors, ParaRev’s STAT Revenue collects millions of underpaid commercial and government insurance dollars. We go account by account to find your unique underpayment issues that are often missed by technology-based vendors. We get you every dime you’re due.

Transfer DRG Review

Hospitals can lose millions in revenue when Medicare and Medicare Advantage patients’ discharge status codes do not reflect the post-acute care received. While receipt of services is outside of your control, we will ensure claims are in compliance and will recover unwarranted payment reductions.

Staff Training & Education

Our process extends beyond underpayment recovery. We provide specialized trainings to bolster your team’s capabilities to resolve systemic errors and increase collection rates. Our best practice recommendations deliver customized and innovative solutions to your hospital to decrease future underpayment exposure.

Contract Consulting

Complex reimbursement methodologies and ambiguous contract language are often the reason behind underpayments. Our review begins with a comprehensive analysis to identify the risks associated with each contract. We’ll collect the insurance revenue you’re due, and help you close contractual loopholes in future negotiations.

Transfer DRG Review

Revenue Capture

Hospitals can lose millions in revenue when Medicare and Medicare Advantage patients’ discharge status codes do not reflect the post-acute care received. While receipt of services is outside of your control, PARAREV’s STAT Revenue team will ensure claims are in compliance and will recover unwarranted payment reductions.

Nationally, the impact of incorrect post-acute transfer payment reductions amounts to hundreds of millions of dollars lost per year. Qualifying Medicare and Medicare Advantage claims receive a payment reduction when patients are transferred to another provider to continue treatment. Unfortunately, patients do not always comply with their discharge instructions and do not receive these post-acute services as planned. This results in improper payment reductions for your hospital.

Our thorough review of qualifying claims to ensure receipt of post-acute care as planned can provide your hospital with a significant boost in revenue. Our proven Transfer DRG Review service allows your hospital to recover unjustified payment reductions for claims with discharges in the last four years.

The review necessary to identify these claims is extremely time consuming and most hospitals don’t have the resources necessary to perform this review themselves.  Let us identify instances of non-transfer to capture this revenue for you, while also giving you the peace of mind your claims are accurately and compliantly reflecting the actual services received.

Staff Training & Education

Revenue Capture

Our process extends beyond underpayment recovery. We provide specialized trainings to bolster your team’s capabilities to resolve systemic errors and increase collection rates. PARAREV’s STAT Revenue team’s best practice recommendations deliver customized and innovative solutions to your hospital to decrease future underpayment exposure.

Our process extends beyond just underpayment recovery. Our goal is to bolster your team’s capabilities and controls to resolve systemic errors and increase collection rates.

Competitors see your hospital’s mistakes as their gain. STAT Revenue is different. We focus on reducing your underpayments year after year. We never withhold information from our clients. Reports detail exactly what we’re finding and how to prevent underpayments going forward.

From complex pricing instruction, contract analysis, appeal best-practices, and escalation tactics, our experience creating and delivering trainings for hospital teams spans all aspects of revenue recovery. Our trainings address significant issues directly and give your staff the tools we’ve used to resolve payment discrepancies.