The question we hear most often: “What is this query for and why do I have to answer it?” We often incorrectly assume that because a physician is an expert in medical procedures, they are also an expert in documenting those procedures. Physicians are responsible for the care and treatment of millions of patients every single day who put their lives, quite literally, in the physician’s hands. However, to consistently maintain and improve upon safety and effectiveness standards, the system relies on more than just the skill and actions of the provider – it also relies on accurate and comprehensive clinical documentation. Precise and comprehensive clinical documentation is essential for: • Appropriate Reimbursement • Quality Metrics and Reporting • Consistency of Treatment Plans  Central to this process is the physician query, a tool employed by medical coders and Clinical Documentation Integrity (CDI) professionals to clarify ambiguities, inconsistencies, or gaps in medical records. For providers, understanding why a query is in their inbox could help change a query from a source of frustration into an opportunity for patient safety and appropriate reimbursement.

The Rising Challenge of Healthcare Denials Healthcare denials are increasing at an alarming rate, creating significant challenges for providers. According to the 2023 Change Healthcare Denials Index, denial rates have risen to 10-15% , up from 6-10% a decade ago. This trend places a strain on revenue cycles, as denials now account for 3-5% of net patient revenue and cost $25 to $50 per claim to rework. For larger health systems, this translates to millions in lost revenue annually . Denials often stem from: Eligibility issues Coding errors Incomplete documentation Untimely filing Duplicate claims Non-covered services These issues delay reimbursements, increase administrative costs, and disrupt cash flow—especially for smaller practices. Why Are Denials Increasing? Several key factors are driving the rise in healthcare denials: 1. Stricter Payer Requirements Payers are enforcing more rigorous guidelines, including prior authorization , detailed medical necessity documentation , and precise coding accuracy . Automated claim review systems are flagging and denying claims at an increasing rate. 2. Regulatory Complexity Frequent updates to ICD-10 and CPT coding standards , along with policies like the No Surprises Act , add administrative burdens that increase the chance of claim processing errors. 3. Workforce Shortages Staffing shortages and turnover in coding and billing departments lead to backlogs and mistakes. Many organizations still rely on outdated systems , lacking AI-powered claim scrubbing or predictive analytics . 4. High-Deductible Health Plans (HDHPs) As more financial responsibility shifts to patients, eligibility verification challenges and higher patient payment denials have become prevalent. Strategies to Reduce Healthcare Denials To mitigate the impact of rising denials, organizations can implement the following data-driven strategies : 1. Strengthen Front-End Processes Verify eligibility and obtain prior authorizations early Ensure accurate patient information collection 2. Improve Coding and Documentation Invest in staff training and clinical documentation improvement (CDI) programs Utilize computer-assisted coding (CAC) tools 3. Leverage Technology Implement AI-powered claim scrubbing Use predictive analytics and automated denial management workflows 4. Monitor Denial Data Track denial rates by payer and reason Establish key performance indicators (KPIs) and conduct regular audits 5. Foster Collaboration Break down silos between revenue cycle teams Create cross-functional groups to address root causes 6. Engage Payers Build strong relationships with payers Negotiate clearer contract terms and resolve disputes efficiently 7. Enhance Patient Communication Educate patients about their financial responsibilities upfront Provide transparent billing statements and assistance with resolving denied claims The Future of Denial Management As healthcare complexity grows, denial rates are likely to continue rising . However, emerging technologies like AI, automation, and enhanced price transparency tools offer hope for reducing denials. Regulatory reforms aimed at simplifying billing processes could further alleviate the burden.  By adopting proactive denial management strategies , investing in technology , and improving internal processes , providers can minimize denials and strengthen their revenue cycles —ensuring long-term financial sustainability and better patient care . Need Help Reducing Denials? UASI offers expert support in denial management and process optimization . Our tailored solutions help reduce denials, improve cash flow, and safeguard your organization's financial health. 📩 Get in Touch: info@uasisolutions.com 🌐 Learn More: www.uasisolutions.com

Balancing Financial Adjustments and Patient Care Amidst Recent Cuts to the Federal Navigator Program On February 14, CMS released a statement announcing cuts to the Federal Navigator Program . These cuts highlight the Trump administration's broader efforts to reduce federal spending on healthcare programs, which will negatively affect patient care and the financial stability of healthcare systems across the country. The CMS Federal Navigator Program is an initiative designed to aid individuals seeking health insurance coverage through the Health Insurance Marketplace through Federally-Facilitated Exchanges (FFEs). Navigators offer free, unbiased help with understanding healthcare options, applying for coverage, and understanding eligibility for financial assistance. This program aims to improve access to health insurance and help consumers make informed decisions about their healthcare options. Revenue cycle leaders will need to adapt to the changes in enrollment patterns and understand the broader impact on reimbursement models while prioritizing access to free and affordable healthcare. Reduced Navigator funding could lead to fewer enrollments in health plans through the FFEs, affecting the number of patients covered by marketplace insurance and altering payer mix. This shift may require mid-revenue cycle leaders to closely monitor enrollment patterns and adjust revenue projections. While lower premiums might benefit individuals without subsidies, those relying on subsidies could face higher out-of-pocket costs, impacting their ability to afford care. Healthcare providers will need to adapt billing and collections strategies to account for fluctuations in premiums and subsidies, while also managing potential changes in reimbursement rates. To navigate these challenges, providers may need to invest in patient education, outreach, and additional support staff to assist with the enrollment process and handle increased claims-related inquiries. The Consequences of Funding Cuts for Low Income Families In addition, the recent reduction in funding for the ACA Navigator program has several implications for low-income families, particularly those who rely on the assistance Navigators provide to access affordable health insurance. The reduction in funding for the Navigator program will make it more difficult for low-income families to access enrollment assistance, creating barriers that could result in missed opportunities or coverage gaps. While some individuals may benefit from lower premiums, those relying on subsidies will likely face challenges navigating changes in the marketplace, which could lead to confusion and increased out-of-pocket costs if they select the wrong plan. Without the personalized support Navigators provide, families may turn to less effective resources, exacerbating stress and potentially worsening health disparities, ultimately impacting long-term health equity and outcomes for low-income individuals. Mid-revenue cycle leaders can take proactive steps to prepare for the changes in the ACA Navigator program while ensuring that patient care for low-income households remains a priority. 

UASI is proud to announce the appointment of Josh Knepfle as the new Chief Technology Officer . With an extensive background in technology leadership, Knepfle brings over 20 years of experience in software development, strategic innovation, and cross-functional team management to the role.

UASI is excited to announce the appointment of Leah Jeffries as Managing Consultant of Strategy. With over a decade of experience in healthcare coding and compliance, Leah brings a wealth of expertise to this role. She has held several Coding Operations and Strategic Account Management positions where she enhanced client satisfaction, streamlined processes, and led healthcare organizations to optimize their revenue cycle. “UASI’s 40-year commitment to improving revenue cycle operations and performance was one of the factors that attracted me to this position. Their history, along with their vision for helping health systems enhance quality, compliance, operational efficiency, reduce denials, and improve financial performance aligns with my personal passion and experience. UASI is reinventing themselves and I’m excited to be part of that.”  The addition of Leah Jeffries further demonstrates UASI’s commitment to delivering results oriented mid-revenue cycle solutions and enhancing customer satisfaction across the healthcare landscape.

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on inpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the compliance concern, the month and year of the initiative and related coding and documentation requirements is included. More importantly, for each inpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts. The Office of the Inspector General’s (OIG) work plan process is dynamic and changes are made throughout the year. This allows the OIG to meet priorities and react to emerging issues. The OIG work plan website is updated monthly. While there are many topics on the work plan, the majority do not apply to coding and documentation. The information below includes an analysis of the following active inpatient topics: · Medicaid Inpatient Hospital Claims with Severe Malnutrition (OIG) · CMS Oversight of the Two-Midnight Rule for Inpatient Admissions (OIG) · Inpatient Hospital MS - DRG Coding Validation (RAC) Medicaid Inpatient Hospital Claims with Severe Malnutrition, Revised 2024 Severe Malnutrition remains an active item on the OIG workplan. Malnutrition can result from treatment of another condition, inadequate treatment or neglect, or general deterioration of a patient’s health. Hospitals are allowed to bill for treatment of malnutrition based on the severity of the condition (mild, moderate, or severe) and whether it affects patient care. Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a claim may result in higher reimbursement as the claim is coded to a higher MS-DRG. Criteria related to severe malnutrition diagnosis and identification of severity is based on two main sets of criteria: · First, the American Society of Parenteral and Enteral Nutrition (ASPEN). o ASPEN criteria include three situations where malnutrition can occur, including: § 1) Acute illness/injury present for less than 3 months; § 2) Chronic illness present for 3 months or longer; § 3) Social and environmental circumstances limiting access or ability to self-care. o In each of these situations, ASPEN criteria has specific measurement related to energy intake, weight loss, muscle mass loss, body fat loss, edema, and reduced grip strength. · The second criteria in the Global Leadership Initiative on Malnutrition (GLIM). o The GLIM criteria include three phenotypical criteria of weight loss, low BMI, and reduced muscle mass as well as two etiological criteria of reduced food intake or absorption, and increased disease burden or inflammation. Documentation of severe malnutrition, as supported by either ASPEN and GLIM criteria, must also be supported by the treatment plan addressing the underlying etiology and continued treatment beyond the acute care setting. UASI Suggested Compliance Activities · Establish CDI and coding policies related to the use of either ASPEN or GLIM criteria in evaluating the documentation of malnutrition. · Provider education · Develop malnutrition education processes for providers with an emphasis on documentation of the appropriate malnutrition criteria. · Provide ongoing and updated education as identified in documentation audits. · Develop an audit plan · Consider a second-level review process for evaluation of malnutrition documentation, prior to release of the claim. · Establish an audit plan for concurrent and/or retrospective audits for a malnutrition diagnosis. CMS Oversight of the Two-Midnight Rule for Inpatient Admissions, Revised 2024 Prior OIG audits identified millions of dollars in overpayments for inpatient claims with short lengths of stay. Instead of billing the stays as inpatient claims, they should have been billed as outpatient claims, which usually results in a lower payment. To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights. The only procedures excluded from the rule were newly initiated mechanical ventilation and any procedures appearing on the Inpatient Only List. Revisions were made to the Two-Midnight Rule after its implementation. OIG plans to audit hospital inpatient claims after the implementation of and revisions to the Two-Midnight Rule to determine whether inpatient claims with short lengths of stay were incorrectly billed as inpatient and should have been billed as outpatient or outpatient with observation. OIG also plans to review policies and procedures for enforcing the Two-Midnight Rule at the administrative level and contractor level. While OIG previously stated that it would not audit short stays after October 1, 2013, this serves as notification that the OIG will begin auditing short stay claims again, and when appropriate, recommend overpayment collections. When a Medicare beneficiary arrives at a hospital in need of medical or surgical care, the physician or other qualified practitioner must decide whether to admit the beneficiary as an inpatient or treat him or her as an outpatient. These decisions have significant implications for hospital payment as not all care provided in a hospital setting is appropriate for inpatient services. Beginning October 1, 2013, CMS adopted the Two-Midnight rule for admissions. This rule established Medicare payment policy regarding the benchmark criteria to use when determining whether inpatient admission is reasonable and necessary. In general, the original Two-Midnight rule states: · Inpatient admissions would generally be payable if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation. The rule was revised in 2016 to permit greater flexibility for determining when an admission that does not meet the benchmark should nonetheless be payable as an inpatient encounter. · Medicare Part A payment is generally not appropriate for hospital stays expected to last less than two midnights. · The documentation in the medical record must support that an inpatient admission is medically necessary. The most recent update to the CMS Two-Midnight Rule occurred in April 2023, when CMS finalized the rule clarifying that Medicare Advantage (MA) plans must also adhere to the Two-Midnight Rule. UASI Suggested Compliance Activities · Collaborate with utilization review (UR) or case management (CM) for potential two- midnight rule issues · If concurrent review processes are in place, review orders to ensure correct patient placement and involve UR as needed Inpatient Hospital MS-DRG Coding Validation, February 2017 This topic remains on the UASI analysis as it is still an active RAC audit topic and there are ongoing audits related to MS-DRG Coding Validation. The background associated with this ongoing audit is noted below. The OIG analyzed paid Medicare Part A claims for inpatient hospital stays from FY 2014 through FY 2019 and identified trends in hospital billing and Medicare payments for stays at the highest MS-DRG severity level. The number of stays at the highest severity level increased almost 20 percent from FY 2014 through FY 2019, ultimately accounting for nearly half of all Medicare spending on inpatient hospital stays. The number of stays billed at each of the other severity levels decreased. At the same time, the average length of stay decreased for stays at the highest severity level, while the average length of all stays remained largely the same. Specifically, nearly a third of these stays lasted a particularly short amount of time and over half of the stays billed at the highest severity level had only one diagnosis qualifying them for payment at that level. Shorter stays are not inherently problematic, but the number of these stays raises questions about the accuracy and appropriateness of the complications billed by the hospital. Although the complications billed suggest sicker beneficiaries, the shorter lengths of stay point to beneficiaries who are less sick. Excluded from this analysis are certain stays that could be expected to be shorter, such as stays during which the beneficiary died. Furthermore, over half of the stays billed at the highest severity level in FY 2019 (54%) reached that level because of just one diagnosis. In total, nearly 2 million stays had just 1 diagnosis (i.e., 1 major complication/comorbidity) that qualified the stay for the highest severity level. The rest of the submitted diagnoses for these stays were either minor complications or not complications. As a result of this analysis, CMS continues to conduct targeted reviews of MS-DRGs and hospital stays that are vulnerable to up-coding (i.e., those that are billed at the highest severity level) and the hospitals that frequently bill for them. Specifically, CMS targets stays at the highest severity level with certain characteristics, such as those that are particularly short lengths of stay or that have only one major complication. CMS also focuses on MS-DRGs that have a high proportion of stays with these characteristics and on the hospitals that frequently bill them. CMS’s RACs currently conduct coding validation reviews that incorporate some of these targeting strategies. [7] In evaluating current audit plans, consider focusing on short stays, especially those with a single CC or MCC or a complex principal diagnosis (e.g., Sepsis, AKI, ARF). UASI also suggests targeting some of the following MS-DRGs for audit depending on your case mix and volume: · MS-DRGs 064 – 066 Intracranial Hemorrhage or Cerebral Infarction · MS-DRGs 193 – 195 Simple Pneumonia and Pleurisy · MS-DRGs 280 – 282 Acute MI Discharged Alive · MS-DRGs 291 – 293 Heart Failure and Shock · MS-DRGs 308 – 310 Cardiac Arrhythmias and Conduction Disorders · MS-DRGs 377 – 379 Gastrointestinal Hemorrhage · MS-DRGs 637 – 639 Diabetes · MS-DRGs 689 – 690 Kidney & Urinary Tract Infections · MS-DRGs 870 – 872 Septicemia or Severe Sepsis · MS-DRGs 981 – 983 Extensive OR Procedures Unrelated to Principal Diagnosis UASI Suggested Compliance Activities · Select targeted MS-DRGs · Evaluate the data for the top 20-25 MS-DRGs and review for any of the above indicators plus any additional MS-DRGs with high volume. · Review the most recent PEPPER reports for MS-DRGs that may be at risk of improper payment. [8] · Establish a prioritized list of MS-DRGs for review. If possible, review cases with short lengths of stay and one MCC/CC. · Develop an audit plan · Establish an audit plan for concurrent and/or retrospective audits. · Retrospective audits can be conducted in part or wholly by incorporating selected MS-DRGs into your audit plan. Problem MS-DRGs can then be incorporated into a concurrent review work queue, if warranted. · Concurrent coding audits should be limited in scope to address specific areas impacting quality reporting and reimbursement. Timeliness is critical as these accounts are held for additional review prior to releasing the bill. Turnaround time to release cases should be short, 24 to 48 hours, to minimize the impact to DNFB (discharged not final billed) daily/weekly goals. · Audits can be conducted either internally or externally. Internal audits should be conducted based on the availability of staff with appropriate technical expertise (in coding and clinical documentation) and proficiency in communicating feedback through written reports and educational sessions. · Determine the audit scope, considering opportunities for cross-departmental collaboration to address multiple risk factors. For example, clinical documentation improvement (CDI) staff may collaborate with coding staff to conduct an audit on sepsis DRGs, addressing both coding and clinical documentation compliance perspectives. · At a minimum inpatient audit should measure and validate the following: · Accurate identification of principal and secondary diagnosis and procedure codes in accordance with official and facility-specific coding guidelines · Accurate MS-DRG or APR-DRG assignment · Accurate POA indicator assigned for all non-exempt diagnosis codes · Accurate Discharge Disposition assignment · Develop corrective action plans, including physician and coder education, based on audit findings. End Notes: 1. OIG Work Plan: https://oig.hhs.gov/reports-and-publications/workplan/index.asp 2. CMS, Approved RAC Topics, last revised 12/01/2024, accessed on January 14, 2025. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics 3. CMS Reminds Hospitals to Use Severe Malnutrition Codes Correctly. October 17, 2023. Article Detail - JF Part A - Noridian 4. Fact Sheet: Two-Midnight Rule; Oct 30, 2015. Fact Sheet: Two-Midnight Rule | CMS

Presented below is an analysis of new and ongoing initiatives under the Office of the Inspector General (OIG) Work Plan [1] and the Centers for Medicare & Medicaid Services (CMS) approved Recovery Audit Contractor (RAC) reviews [2] as of January 2025. The focus is on outpatient initiatives related to HIM coding and documentation requirements and is not intended to review every active work plan item. For each relevant initiative, a summary of the OIG or RAC compliance concern, the month and year published and added to the plan, and related coding and documentation requirements is included below. More importantly, for each outpatient initiative presented, UASI has included specific suggested compliance activities to assist our clients with their ongoing compliance efforts. The information below includes an analysis of the following active outpatient topics: · Medicare Payments for Lower Extremity Peripheral Vascular Procedures (OIG) · Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes (OIG) · Audits of Medicare Part C Health Risk Assessment Diagnosis Codes (OIG) · Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (RAC) · Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS) (RAC) · Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (RAC) Medicare Payments for Lower Extremity Peripheral Vascular Procedures, June 2024 Minimally invasive procedures aiming to improve blood flow when arteries narrow or become blocked because of peripheral arterial disease have been identified by CMS and whistleblower fraud investigations as vulnerable to improper payments. OIG will analyze Medicare fee-for-service for peripheral vascular procedures for questionable characteristics and review the program integrity activities of CMS and its contractors to combat fraud, waste, and abuse specific to these procedures. Additionally, these procedures will be assessed to ensure compliance with CMS requirements and meet applicable treatment guidelines. Documentation should include: · A description of the studies performed, and any contrast media and/or radiopharmaceuticals used · Any patient adverse reactions and/or complications · Normal and abnormal findings and comparison with prior relevant studies · Variations from normal should be documented along with measurements. · The report should address or answer any specific clinical questions. · Results of all testing must be shared with the referring physician · Adequate documentation to support medical necessity of performing non-invasive vascular studies · medically necessary follow-up noninvasive vascular studies post-angioplasty is dictated by the vascular distribution treated CMS expects that non-invasive vascular studies are not performed more than once a year. A complete review of billing and coding requirements, including the CPT codes and an extensive list of ICD-10-CM codes that support medical necessity can be found at Article - Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593) (cms.gov) Medicare Part C Audits of Documentation Supporting Specific Diagnosis Codes, November 2023 This is the first of two workplan items focusing on high-risk diagnoses that might result in inaccurate risk adjusted data. The first item focuses on quality of the documentation supporting the diagnoses and the second item: Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes focuses on code accuracy, Payments to Medicare Advantage (MA) organizations are risk-adjusted based on each enrollee's health. Inaccurate diagnoses may cause CMS to pay MA organizations improper amounts. In general, MA organizations receive higher payments for enrollees with more complex diagnoses. CMS estimates that 9.5 percent of payments to MA organizations are improper, mainly due to unsupported diagnoses submitted by MA organizations. Prior OIG reviews have shown that some diagnoses are more at risk than others to be unsupported by medical record documentation. We will perform a targeted review of these diagnoses and will review the medical record documentation to ensure that it supports the diagnoses that MA organizations submitted to CMS for use in CMS's risk score calculations and to determine whether the diagnoses submitted complied with Federal requirements. Nationwide Audits of Medicare Part C High-Risk Diagnosis Codes, November 2023 Medicare Advantage (MA) organizations receive risk-adjusted reimbursement based on the health status of each enrollee. All MA organizations submit risk-adjustment data to CMS according to defined regulations. Mis-coded diagnoses can result in incorrect payments back to MA organizations. These audits will focus on identified high risk diagnoses being mis-coded and resulting in increased risk-adjusted payments from CMS. In a previous CMS audit of high-risk diagnoses, 183 of the 280 sampled enrollee-years, resulted in the following findings: 1) the medical record(s) provided did not support the diagnosis code(s) or 2) the medical record(s) could not be located; therefore, the diagnosis code(s) was not validated. [3] Through data mining techniques and meetings with medical professionals, CMS identified diagnoses that are at a higher risk of being miscoded. These diagnoses include: · Major depressive disorder: Concerns related to this diagnosis note that the diagnosis was documented but the patient did not have an antidepressant medication prescribed. As such, a major depressive disorder may not be supported in the documentation. · Acute stroke: Findings for this diagnosis noted that an acute stroke diagnosis on a physician claim during a service year does not correspond to an inpatient or outpatient hospital claim. · Vascular claudication: The vascular claudication findings noted a diagnosis during the service year which was not present during the preceding 2 years. · Cancer: Findings related to several cancer diagnoses in this audit were related to a cancer diagnosis during the service year, however no treatment (e.g., surgery, radiation, or chemotherapy) was found within a 6-month period before or after the diagnosis. A diagnosis of history of cancer may be more appropriate. These cancer diagnoses include: o Breast cancer o Colon cancer o Prostate cancer o Lung cancer · Acute myocardial infarction (AMI): These specific findings noted diagnoses of acute myocardial infarction on a physician or outpatient claim during the service year. However, there was not an AMI diagnosis on a corresponding hospital claim. A code for the history of MI may be more appropriate. · Embolism: Enrollees received a diagnosis of acute or chronic embolism without an anticoagulant medication, which is typically used to treat an embolism. The history of embolism diagnosis may be more appropriate. These findings confirm the CMS intention to continue auditing for and enforcing complete and accurate clinical documentation. UASI Suggested Compliance Activities for this Initiative 1. Improve population health data analytical capabilities and monitor high risk diagnosis reporting. 2. Utilize reports to determine the frequency of these high-risk diagnoses associated with risk-adjustment enrollees. Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint, June 2023 Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary. The only code included in this review is CPT code 27279, Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device. Additional procedure coding information can be found in the CPT Assistant, April 2023, Volume 33, Issue 4, page 16. There are multiple different ICD-10-CM diagnosis codes that support the medical necessity for this procedure. ICD-10-CM Diagnosis Code Code Description M43.27 Fusion of spin, lumbosacral region M43.28 Fusion of spin, sacral and sacrococcygeal region M46.1 Sacroiliitis, NEC M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M53.2X7 Spinal instabilities, lumbosacral region M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.3 Sacrococcygeal disorders, NEC M533.87 Other specified dorsopathies, lumbosacral region M53.88 Other specifies dorsopathies, sacral and sacrococcygeal region M99.14 Subluxation complex (vertebral) of sacral region S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter S33.2XXD Dislocation of sacroiliac and sacrococcygeal joint, subsequent encounter S33.2XXS Dislocation of sacroiliac and sacrococcygeal joint, sequela S33.6XXA Sprain of sacroiliac joint, initial encounter S33.6XXD Sprain of sacroiliac joint, subsequent encounter S33.6XXS Sprain of sacroiliac joint, sequela S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter S33.8XXD Sprain of other parts of lumbar spine and pelvis, subsequent encounter S33.8XXS Sprain of other parts of lumbar spine and pelvis, sequela Coverage Indicators [4] This procedure is considered medically necessary when ALL the following criteria are met: · Have moderate to severe pain with functional impairment and pain persists despite a minimum six months of intensive nonoperative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ, and hip including a home exercise program · Patient’s report of typically unilateral pain that is caudal to the lumbar spine (L5 vertebrae), localized over the posterior SIIJ, and consistent with SIJ pain · A thorough physical examination demonstrating localized tenderness with palpation over the sacral sulcus in the absence of tenderness of similar severity elsewhere and that other obvious sources for their pain do not exist · Positive response to a cluster of 3 provocative tests · Absence of generalized pain behavior · Diagnostic imaging studies that include ALL the following o Imaging (plain radiographs and a CT or MRI) of the SI joint that excludes the presence of destructive lesions, fracture, traumatic SIJ instability, or inflammatory arthropathy that would not be properly addressed by percutaneous SIJ fusion. o Imaging of the pelvis (AP plain radiography UASI Suggested Compliance Activity for this Initiative 1. Utilize reports to determine the frequency of CPT code 27279. 2. Based on these findings, determine the need to audit a percentage of the total cases. Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS), April 2023

Taxpayers spend an average of $2.5 trillion overall for healthcare in the United States as the healthcare industry continues to face complex challenges in the coming year. While this is happening, providers feel the growing financial burden as tensions continue to rise between payers and providers. Understanding the current landscape will allow organizations, providers, and payers to proactively prepare their internal processes to meet industry needs and standards. As a reference point, in January 2024, national health spending grew by 6.0% since January 2023 and represented 17.4% of GDP. Nominal GDP in January 2024 was 5.1% higher than in January 2023, growing more than 0.8 percentage points more slowly than health spending. The Health Research Institute (HRI) of Price Waterhouse Cooper recently predicted 2025 to have the highest medical cost trend in 13 years. HRI asserts that this trend is “driven by inflationary pressure, prescription drug spending and behavioral health utilization”. Even with the rising cost of healthcare, there is a decrease in overall revenue. What CFOs should be aware of is that this financial pressure will affect cash flow, reimbursement rates, and the ability to maintain margins. Each day, we’ll be highlighting a critical area that mid-revenue cycle leaders should prioritize to prepare for these market shifts and reduce revenue leakage in 2025. The 5 areas we’ll cover include: #1 SDoH and Reimbursement Impact #2 Tackling the Growing Threat of Claim Denials #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities #4 Harnessing Artificial Intelligence #5 Reduce Penalties Through Accurate PSI Reporting #1 Social Determinants of Health (SDoH) & Reimbursement Impact The current focus on Social Determinants of Health (SDoH) will continue into 2025. The Inpatient Prospective Payment System (IPPS) final rule provided some good news related to SDoH. CMS plans to increase the federal standard rate by 2.9%. Part of this increase is a change in severity assignment for some SDoH codes. Specifically, treatment plans or encounters related to inadequate housing or housing instability will become a CC (Comorbidity Code) in 2025. The rationale for the changes in severity is due to the anticipated higher than average resource costs associated with these patients. According to the U.S. Department of Health and Human Services, “In the FY 2024 IPPS final rule, CMS finalized a policy change to recognize the higher costs that hospitals incur when they provide hospital services for individuals experiencing homelessness. Building on this policy and the Biden-Harris Administration’s initiative to address unsheltered homelessness, CMS is taking an additional step to better account for the resources involved in furnishing care to individuals experiencing housing insecurity, meaning that hospitals will generally receive higher payments when a patient is experiencing housing insecurity.” Healthcare leaders in the mid revenue cycle can reduce revenue leakage by focusing on accurate documentation and coding of SDoH. In particular, accurate documentation related to housing insecurity should be a critical focus as the 2025 IPPS changes will increase reimbursement rates for these patients. Accurate documentation of SDoH codes will not only improve reimbursement but also help address the higher resource costs associated with treating this patient population. Read our recent article on SDoH to learn more! SDoH Can Make a Big Difference in Patient Care and Reimbursement #2 Tackling the Growing Threat of Claim Denials As we move into 2025, claim denials are expected to remain a significant challenge for healthcare providers and organizations. Denied claims disrupt cash flow, create additional administrative burdens, and can even impact the quality of patient care. According to a recent survey by Experian Health, 38% of healthcare professionals reported that one in every ten claims is denied, while 73% noted that denials rates are on the rise. This increase of denials is putting additional strain on already overburdened healthcare systems and making it harder for providers to maintain operational efficiency. Most healthcare systems are struggling to address the growing volume of claim denials, and because of the administrative burden, fixing the root cause is often overlooked. With increasing claim volumes and complex payer requirements, healthcare providers are overwhelmed by the sheer number of denials in addition to the need to meet multiple deadlines for denials appeals. Compounding this challenge is the lack of specialized expertise in handling claim denials, which makes organizing the workflow and managing the appeals process difficult. Healthcare organizations that fail to address their claim denials are left vulnerable to revenue leakage through missed opportunities for reimbursement. Conducting a denials program assessment is a necessary first step in understanding the root causes of denials and identifying areas for improvement. An assessment can help organizations gain insight into denials trends, develop targeted strategies to reduce denials, and identify ways to implement more efficient workflows. Additionally, an assessment can help identify where education and training are needed to improve accuracy and prevent denials altogether. Many systems find it difficult to even address all the denials as they come in, so they find it challenging to conduct an assessment. Partnering with a third-party authority can help with capacity to get an assessment completed but also provide an objective perspective. In addition, an outsource partner and/or implementing A.I. can help alleviate the burden and cover more volume. An assessment can help identify the best options to solve the problem. #3 Avoid Costly Recoupments & Identify Missed Reimbursement Opportunities In 2024, the Office of Inspector General (OIG) identified several areas in healthcare billing that could cost the American taxpayers billions of dollars in recoupments. To note, the OIG conducts audits to ensure that healthcare claims are compliant with federal regulations. For example, one of the significant findings from the OIG in 2024 was noncompliance with the “two-midnight rule”, which requires a patient’s hospital stay to span two midnights to qualify for inpatient payment. In 2025, OIG audits are expected to continue focusing heavily on validating claims data, ensuring accurate code assignment, and confirming that clinical documentation supports medical necessity. Healthcare systems must prepare for increased scrutiny of their claim’s data. Without a process in place to identify discrepancies in documentation early on, healthcare providers risk triggering unnecessary OIG audits, which could result in costly recoupments. Often, third-party audits are conducted too late once discrepancies have already led to compliance issues and financial loss. This reactionary approach can be avoided by completing preemptive reviews and audits before an official OIG audit occurs. To stay ahead, healthcare organizations must shift their mindset from a reactive to a proactive approach. By conducting regular, ongoing audits or reviews, providers can identify risks and address pitfalls before they escalate into major compliance issues. Furthermore, healthcare systems who elect to conduct proactive 3rd party audits, should view them not merely as a tactic to avoid OIG audits, but as a larger, strategic move to boost ROI by ensuring accurate coding and reimbursement opportunities. Preliminary audits arm healthcare systems with the information and resources to comply with federal regulations while discovering opportunities for increased revenue. #4 Harnessing Artificial Intelligence In utilizing vast amounts of data, A.I. can be harnessed to increase productivity. With these advancements and their impact on the revenue cycle, it is leaving industry experts wondering how the function of accurate code assignment will look in the future. In addition, for smaller healthcare organizations with lower patient volumes, the adoption of A.I. may seem out of reach. This leaves many leaders in the mid revenue cycle uncertain about how to begin integrating these technologies into their operations. As the technology develops and improves, A.I. has the potential to reduce administrative burdens and address the complexity of billing and coding accuracy while improving patient care. These potential improvements could impact the financial health and sustainability of hospitals and physician groups nationwide. To combat healthcare’s rising costs, increase in payer denials, and the need for accurate code assignment, the integration of AI into the revenue cycle will likely become a key competitive differentiator for healthcare organizations in 2025. While the integration of A.I. in CC (Code Capture) has become more widespread, the technology often requires significant volume, so many smaller healthcare facilities have yet to benefit. In addition, the more complex aspects of coding still require human oversight and expertise. The challenge that many health systems face is in regard to identifying the right tool and how to begin integrating new tools into an already established workflow. Partnering with firms that can assist in evaluating AI tool options, help healthcare facilities manage the people processes, and develop the roadmap associated with these new technologies to ensure ROI, is worth consideration. Short term spend for long-term benefits. #5 Reduce Penalties Through Accurate PSI Reporting Patient Safety Indicators (PSIs) are a set of measurement tools developed by the Centers for Medicare and Medicaid Services (CMS) to track adverse patient outcomes, such as hospital-acquired infections, falls, and other complications. These indicators are used to assess the quality of care provided by hospitals and highlight areas where patient safety can improve. Hospitals are required to report PSIs to CMS as part of their participation in Medicare and Value-Based Care programs. PSIs directly impact revenue through penalties and reduced reimbursements. Hospitals with high rates of hospital-acquired conditions are penalized with lower reimbursements, particularly if they rank in the bottom 25% of PSI 90 scores. Despite improvements in PSI reporting, CMS consistently penalizes the lowest performing facilities. In addition, as the healthcare industry continues shifting to Value Based Care (VBC), a portion of Medicare reimbursements will continue to be tied to PSIs making accurate PSI reporting more crucial than ever. It bears mentioning that public PSI data can also harm a hospital's reputation, leading to reduced patient volume and further revenue loss. To reduce revenue leakage caused by inaccurate PSI reporting, healthcare systems must focus on improving the accuracy of their documentation and coding. Many reported PSIs can be avoided if accurately documented, especially by drawing on the knowledge of Clinical Documentation Integrity (CDI) and Quality experts. For example, establishing accurate present on admission (POA) status through simple queries can remove patients from specific PSI categories. In addition, understanding the specific exclusion diagnoses for PSIs, like those related to elective surgeries, can prevent inaccurate PSI reporting. Want to learn more about Patient Safety Indicators? Read our lates article on PSIs to learn more: Patient Safety Indicators: Aligning CDI and Coding with Quality Goals

1. The Expiration of ACA Subsidies Enhanced subsidies under the Affordable Care Act (ACA) are set to expire at the end of 2025. If Congress does not extend these subsidies, premiums for many enrollees could surge by more than 75%, leading to a significant rise in uninsured patients. For healthcare organizations, this could mean a decrease in commercially insured patients and an increase in Medicaid or uninsured populations, driving up uncompensated care and bad debt . Steps to Prepare: Identify Revenue Impact: Conduct financial modeling to assess the potential impact of payer mix shifts on your revenue. Optimize Medicaid Processes: Strengthen Medicaid eligibility and enrollment workflows to reduce gaps in reimbursement. Enhance Financial Counseling: Train staff to assist patients in exploring available insurance options and payment plans. By proactively addressing these areas, organizations can minimize revenue leakage and maintain financial stability. 2. Potential Changes to Medicare’s Inpatient Only List Efforts to phase out Medicare’s Inpatient Only (IPO) list have been a contentious topic. While earlier attempts to eliminate the list were reversed, a renewed focus on reducing covered inpatient procedures is possible. Hospitals may face increased pressure to justify inpatient admissions to ensure proper reimbursement. Steps to Prepare: Review Care Protocols: Ensure inpatient admissions align with Medicare guidelines by conducting regular audits. Strengthen Documentation: Partner with CDI experts to bolster clinical documentation supporting medical necessity. Develop Training Programs: Educate care teams on evolving regulations and documentation best practices. These measures will help organizations navigate the transition while securing appropriate reimbursements. 3. Medicare Advantage Expansion The growth of Medicare Advantage plans continues to raise concerns for providers. These plans often deny claims at twice the rate of commercial insurance , adding administrative burdens that strain resources. Any expansion of these plans could significantly affect hospital cash flow and operational efficiency. Steps to Prepare: Conduct a Denials Assessment: Identify root causes of denials and implement corrective action plans. Automate Claims Processes: Leverage technology to streamline workflows and improve claims accuracy. Partner with Experts: Collaborate with a third-party partner like UASI to manage denials efficiently and reduce administrative strain. By taking these steps, healthcare organizations can mitigate the impact of Medicare Advantage expansion on revenue cycles. 4. The Rise of Site-Neutral Payment Policies Site-neutral payment policies—requiring Medicare to reimburse services equally across care settings—pose another potential challenge. While aimed at cost savings, these policies often overlook the higher operating costs of hospitals, which provide 24/7 care and meet rigorous regulatory requirements. A mid-sized health system, for example, could lose upwards of $5 million annually under expanded site-neutral rules. Steps to Prepare: Analyze Service Lines: Evaluate which services are most vulnerable to site-neutral payment changes and adjust strategies accordingly. Advocate for Fair Reimbursement: Join industry groups to advocate for policies that reflect the higher costs of hospital-based care. Diversify Revenue Streams: Explore alternative revenue opportunities, such as outpatient services and partnerships. Preparing for these changes will position providers to adapt to regulatory shifts and safeguard financial health. Leveraging Industry Insights for Better Outcomes Industry trends highlight the critical importance of reducing revenue leakage through proactive strategies. These include improving documentation accuracy, conducting denial program assessments, and leveraging innovative technologies like AI. By aligning your organization with these approaches, you can address common challenges such as rising denial rates, compliance risks, and inefficiencies in revenue cycle management. UASI’s expertise supports these priorities by helping providers strengthen their financial and operational performance. Whether it’s addressing the impact of payer mix changes, improving claims accuracy, or mitigating regulatory risks, our tailored solutions empower organizations to navigate an increasingly complex healthcare environment. UASI remains a trusted partner through change and uncertainty, offering the expertise and support needed to navigate these challenges while driving financial and operational success for healthcare organizations. References: ACA Subsidies Impact: https://www.kff.org/interactive/how-much-more-would-people-pay-in-premiums-if-the-acas-enhanced-subsidies-expired/ Medicare Inpatient Only List Updates: https://www.findacode.com/newsletters/aha-coding-clinic/hcpcs/cy2024-changes-medicares-inpatient-list-H241004.html Medicare Advantage Expansion Concerns: https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743 Site-Neutral Payment Policy Analysis: https://www.aha.org/fact-sheets/2023-03-21-fact-sheet-medicare-hospital-outpatient-site-neutral-payment-policies

“Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” On December 4, 2024 , Title 42 of the Medicare Advantage plan was amended by CMS and the goal was to implement reforms that will ultimately improve healthcare access, quality, and equity for Medicare beneficiaries . This change is related to executive order 14110 by the Biden-Harris Administration, “Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence” which ensures that the development of AI does not jeopardize the advancement of equity and civil rights especially in health organizations. Institutions that do not comply with this amendment will be subjected to possible prosecution. Artificial Intelligence (AI) is rapidly becoming a prominent force in our society, and its application in healthcare is viewed with both hope and caution . Health information professionals must understand what AI entails, its capabilities, and how to employ it responsibly and ethically. With increased use of AI in healthcare, questions arise about maintaining patient trust and safeguarding data integrity , especially given the discrepancies and accuracy rate of AI-driven data collection and analysis. Additionally, with the increasing automation of revenue cycle operations in healthcare systems, ensuring coding accuracy, billing, and documentation in this evolving landscape becomes even more crucial . AHIMA and GDHP Partner for First Health Information Summit In November AHIMA and IFHIMA joined forces and conducted the first global policy summit of health information professionals and presented on public issues related to the health information profession in collaboration with GDHP (Global Digital Health Partnership), a collection of national digital health authorities and the World Health Organization (WHO). In short, digital health is the “systematic application of information and communications technologies, computer science, and data to support informed decision-making by individuals, the health workforce, and health institutions, for strengthened resilience and improved health and wellness for all.” Digital health includes digital technology-based data fields e.g., data analytics, artificial intelligence, eHealth, and telemedicine, to name a few. A central concern of the summit was the evolving impact of digital health technologies, in particular the implementation of AI, and the priorities and needs of professionals within the health information sector as they relate to digital health. During the summit, key policies were discussed that are currently impacting the health information profession. UASAID Recommended Practices  In addition to the global policy health summit, the United States Agency for International Development (USAID) recently released a position paper titled Digital Health which outlined four priorities for programmatic digital health investments . These focal areas underscore the federal government’s strategic emphasis on advancing digital health technologies . These priorities range from strengthening a country’s digital health environment to aligning digital health investments with national architecture. Additional recommended practices outlined by USAID include: · Requiring standards to enable integrated health care service delivery at scale . · Establishing standards that equate to better coordination of care , and deepening engagement with local partners . · Engaging with local partners including the private sector to support the ability of global health funders like USAID to be effective long-term partners to government ministries of health. Preparing for AI Advancement in the Mid Revenue Cycle CFO’s and Directors of HIM need to ensure compliance with CMS regulations while preparing for stricter federal-level oversight in addition to monitoring the overall performance of AI solutions. The need for education and training will continue to grow to accurately assess AI-driven data, ensuring that decision-making remains informed and aligned with regulatory standards. UASI collaborates with healthcare systems to enhance workforce capabilities in exchanging and using relevant healthcare data by reviewing and identify coding and documentation errors that impact revenue integrity and patient care , ensuring the accuracy and integrity of patient information. UASI is committed to supporting the digital transformation of health systems with long-term vision of achieving data interoperability , ensuring equity in the use of AI , and creating globally sustainable health systems .

Value-based care (VBC) models are continuing to gain traction to improve care outcomes while controlling costs. However, the transition to VBC comes with its own set of challenges, specifically around risk adjustment, which is vital to ensuring accurate reimbursement. To better understand these hurdles, UASI asked industry leaders for their insights into the complexities of implementing and managing Risk Adjustment in VBC models. Key Challenges in Adopting VBC Models Industry leaders in healthcare highlighted several challenges related to adopting Value-Based Care models and identified several barriers; Staff resistance to new care delivery and reimbursement models, and a lack of education and training hinders understanding and adoption of VBC. Aligning processes and workflows with new care models can disrupt established practices, while difficulties in aligning with payor contracts, due to varying quality metrics and reimbursement formulas, create further obstacles. Additionally, many healthcare systems face inadequate operational capacity and a shortage of a specialized workforce , making it difficult to scale VBC models effectively. Resources for VBC Implementation and Optimization To effectively manage value-based care (VBC) models , industry leaders weighed in and identified several key resources to better support VBC implementation. Those organizations with more mature programs have 6 key components in place in managing a successful program: The main needs identified were data analytics to track patient outcomes and costs Comprehensive training and education programs to equip staff with the knowledge to effectively implement VBC. Leaders in Risk Adjustment would like to see a defined strategy and objectives within their organizations to guide decision-making The tools and technology to support the strategy. Financial incentives from payors are needed such as quality measures and shared savings programs to leverage more support for VBC implementation. Regulatory guidance can also help health systems to navigate VBC complexities and ensure compliance. Challenges in Data Accuracy and Metrics for Evaluating Success Data accessibility and accuracy are major barriers within Risk Adjustment. Ensuring that data is comprehensive and accurate is needed for calculating risk scores and understanding where to focus efforts. With multiple risk adjustment models in place, organizations struggle to find processes that create efficiencies. Additionally, provider burnout and workflow management issues arise as providers navigate various VBC models. To ensure effectiveness, there are a set of metrics to evaluate Risk adjustment and value-based care models: Hospital Readmission Rates : Reducing hospital readmissions indicates the success of preventive care and is a goal of VBC. · Mortality Rates : Mortality rates focus on the overall quality of care and patient outcomes. Cost per Patient per Month (PMPM) and Total Cost of Care : Tracking the cost per patient is essential to managing the financial aspects of VBC, ensuring that the system remains financially viable while improving care quality. Total cost of care is a broad metric that captures the financial efficiency of the care model. Shared Savings Revenue : This metric tracks the financial savings generated through VBC initiatives, which are shared between providers and payors. Quality Scores (HEDIS, STAR Ratings) : National quality measures such as HEDIS and STAR ratings provide objective benchmarks for evaluating the effectiveness of care delivery. Risk Adjustment Accuracy Scores (RAF, Recapture Rate) : These scores are essential for evaluating the precision of risk adjustment models. RAF is the estimated yearly cost to treat a patient whereas the Recapture Rate refers to how well a provider captures recurring HCC diagnoses and is also used to understand future healthcare costs. Suggestions for Improvement Improvements must be organizational and system wide as industry leaders highlight that viewing Risk Adjustment and VBC as just a revenue cycle or coding issues is a major barrier. Instead, these challenges require an integrated approach involving clinicians, administrators, and payors to drive the necessary changes . As previously stated, healthcare organizations face challenges like staff resistance, workflow management, and data accessibility/accuracy. However, with the right resources these obstacles can be overcome. Let UASI help you bridge the gap by assessing your Risk Adjustment practices, identify gaps, and develop targeted solutions.

In 2021, the New Technology Add-on Payment (NTAP) program was created by The Center for Medicare & Medicaid Services (CMS) to increase the use of new inpatient technologies in the Medicare population. CMS uses NTAP codes for qualifying products that promise improvement in process or outcomes. Additionally, these new medical services and technologies are eligible for an add-on payment known as NTAP which presents significant reimbursement opportunity for hospitals and healthcare systems that adopt these technologies. Eligibility Criteria for NTAP Payments To be eligible for the NTAP, these technologies must meet the following 3 criteria. When the following criteria are met, the NTAP payments are significantly greater than the standard Medicare Severity Diagnosis-Related Group (MS-DRG). 1.) Technology must be new within 2-3 years of market introduction. 2.) The technology must “substantially improve the diagnosis or treatment relative to currently available technologies and are inadequately paid otherwise under the current diagnosis-related group (DRG) reimbursement rates.”1 3.) The technology is deemed inadequately compensated under the current MS-DRG, as its average standardized charge for inpatient cases exceeds the set cost threshold. FY 2025 Program Expansion: 39 New Technologies Approved The number of approved technologies has increased each year since its inception. The FY 2025-year list is the most extensive since the program began and includes 39 Total NTAPs. • CMS finalized the continuation of new technology add-on payments for 24 existing new technologies • CMS finalized discontinuing new technology add-on payments for 7 current new technologies • CMS finalized 16 of the original 27 new technologies submitted for new technology add-on payments under the traditional and alternative pathways Financial Impact: What NTAP Can Mean for Your Hospital’s Reimbursement According to CMS, new technology add-on payments are limited to the lesser of 65% of the costs of the technology, or 65% of the amount by which the costs of the case exceed the standard MS–DRG payment”. The most substantial financial impact approved for FY 2025 Casegevy and Lyfgenia. Both are medications for gene therapies that treat sickle cell disease. These medications qualify for 75% NTAP amount resulting in a maximum payment of $1.65 Million for Casgevy and $2.32 Million for Lyfgenia. Key Steps to Maximize NTAP Reimbursement For hospitals and health systems, it is essential to take the following steps to ensure full NTAP reimbursement: Accurate Coding: Make sure the correct ICD-10-PCS code(s) are included on claims to qualify for NTAP payments. Missing or inaccurate codes can lead to lost revenue. Annual Review of NTAP Services: Each year, inpatient coding staff should review the latest list of approved NTAP services and technologies to stay updated on new opportunities for reimbursement. Routine Audits: Conduct regular internal and external audits to confirm that all eligible procedures and technologies are correctly coded and reimbursed. These audits help identify and prevent potential revenue leakage. Taking these proactive measures can help ensure your hospital captures all eligible NTAP reimbursements. Not Sure if You’re Capturing All Possible NTAP Revenue? Contact UASI for a comprehensive NTAP assessment. Our expert audit team is ready to help your hospital secure eligible NTAP payments and maximize revenue potential. Do not let money slip through the cracks - Reach Out Today! References 1. Adoption and Trends in the Medicare New Technology Add-On Payment Program - PubMed Central (PMC) 2. New Medical Services and New Technologies - Centers for Medicare & Medicaid Services (CMS)

In today’s complex healthcare environment, optimizing the revenue cycle is more crucial than ever. As healthcare systems face increasing financial pressures, effective revenue cycle management (RCM) is essential for maintaining both operational efficiency and financial health. Leslie Vairo, Senior Consulting Director in Revenue Cycle at Vizient, is at the forefront of helping health systems navigate these challenges. With her broad experience in healthcare and finance, Leslie's expertise is key to helping enhance hospital operations and maximize revenue streams. As a leading healthcare performance improvement organization, Vizient partners with more than half of US healthcare organizations. The organization provides end-to-end assessments that help organizations improve performance, increase revenue, and optimize their operations. By working closely with health system leadership, Vizient conducts assessments of the revenue cycle process, that include denials management to coding accuracy, identifying areas where there is revenue leakage. The goal is to develop long-term strategies for sustainable improvement.  3 Common Revenue Cycle Challenges During assessments, Leslie noted that Vizient often encounters recurring issues that contribute to lost revenue Denials Management: Often, hospitals struggle with authorization errors, inaccurate coding, and unresolved payment issues, all of which can delay or prevent reimbursement. These issues are exacerbated by outdated systems and a lack of standardized processes across different payers, especially with Medicare and other insurers that have different billing guidelines. Aging Coding Staff & Coding Accuracy: The healthcare industry faces a growing shortage of qualified medical coders, which has led to an aging coding workforce. In addition, Leslie noted that coding accuracy is a major issue, with some facilities reporting accuracy rates below 90%. Hospitals often don’t realize how much this shortfall costs them in lost revenue. The financial strain is also compounded by the backlogs of charts that is a direct result of the medical coding staff shortage. Revenue Leakage: Underpayments or overpayments are another key issue that delays revenue flow. Often referred to as revenue leakage, these discrepancies result from inefficient claims processing or errors in billing, leading to delayed or lost payments. Leslie’s assessments reveal that many hospitals have significant opportunities to recoup revenue by improving accuracy in their coding and billing procedures. People, Process & Partnerships Hospitals are often eager to invest in new technologies, but Leslie points out that technology alone is not enough. Many hospitals purchase systems like EPIC or are now considering AI, hoping the technology will automatically improve their revenue cycle performance. However, without addressing the people and processes that drive the technology, the return on investment (ROI) is often limited. Hospitals must focus on aligning technology with the necessary skill development and change management to maximize its effectiveness. One of the barriers Leslie encounters is the resistance to change from hospital staff, particularly when it comes to legacy teams that have not looked at or updated their program’s operations. These barriers can be especially pronounced when hospitals are presented with data analysis that shows they are leaving millions of dollars on the table due to inefficiencies in their revenue cycle. Overcoming this resistance requires not only clear communication in these assessments but also demonstrating the tangible financial benefits that can result from program optimization. As hospitals strive to address these challenges, especially in the face of staffing shortages, it becomes necessary to partner with external vendors to fill critical roles in the revenue cycle. Leslie says that partners like UASI can bring much-needed specialized resources to help streamline the revenue cycle and stay up to date in a dynamic environment. These partnerships also enable hospitals to access skilled professionals who can address coding and billing challenges while maintaining compliance. Advice for New Rev Cycle Leaders For new leaders stepping into revenue cycle roles, Leslie offers several key pieces of advice to help set them up for success: 1. Review Historical Data : Look back at accounts receivable (AR) and collections trends to establish a benchmark. Most hospitals focus on current performance without comparing it to historical data, which makes it harder to identify trends and areas for improvement. 2. Build Strong Relationships : Work closely with hospital executives and make sure that everyone understands the importance of the revenue cycle. As Leslie points out, the revenue cycle is an integral part of a hospital’s financial health and getting buy-in from leadership is essential for driving change. The Path Forward for Health Systems Revenue cycle management is more than just a financial function, it is a critical component of operational success and therefore, impacts patient care. By addressing issues like coding accuracy, denials management, and staffing shortages, hospitals can unlock significant revenue opportunities and improve their overall financial health. Hospitals that take a comprehensive approach to their revenue cycle will be better positioned to deliver high-quality care while maintaining financial sustainability. Reach out today to learn how a UASI & Vizient partnership can help impact quality outcomes and improve organizational sustainability. Contact Us Today!

Can Providers Truly Win?

Cincinnati, OH — UASI is excited to announce the addition of Rachel Mack, MSN, RN, CCDS, CDIP, CCS, CRC, to the team as Managing Consultant in Clinical Documentation Integrity (CDI). Rachel brings over 15 years of experience in CDI and healthcare management, with a well-rounded background as a CDI Specialist, Educator, and Auditor. Her expertise in inpatient hospital CDI/coding, CDI technology, risk adjustment methodologies, and Medicare will significantly enhance UASI's commitment to delivering exceptional documentation solutions. Rachel has demonstrated her dedication to advancing CDI through her strong leadership in program and project management, with a Master's degree in Nursing Administration from Jacksonville University. She has worked closely with physicians to implement effective CDI strategies and has a proven track record in PSI prevention and Medicare compliance. “I am passionate about all things CDI and am thrilled to bring my experience to UASI,” said Rachel Mack. “I look forward to working with a team that shares my commitment to enhancing healthcare outcomes through innovative CDI practices.” Rachel's industry influence extends beyond her work with hospitals. She has been a sought-after speaker at major industry conferences, including her recent presentation on Social Determinants of Health (SDoH) at the 2023 ACDIS Conference alongside Connie Ryan. She also organized and presented at Vizient’s webinar series in 2021, 2022, and 2023, covering topics like CDI and Cardiac Surgery, Sepsis, Respiratory Failure, Risk Adjustment, and PSIs/HACs. Rachel's expertise and thought leadership were also featured at several ACDIS Conferences. About UASI For over four decades, UASI Solutions has led the healthcare industry in revenue cycle management, providing tailored solutions to optimize fiscal performance and drive sustainable growth. Established in 1984, our commitment to innovation and client success has solidified our position as trusted partners nationwide. With a comprehensive suite of services, including Remote Coding, Clinical Documentation Improvement, and Revenue Integrity, we remain dedicated to delivering value and driving results for our clients every step of the way. For more information, please visit www.uasisolutions.com .

Healthcare is evolving, and as we move forward with quality care and compassion, it’s crucial to address the factors that significantly impact patient outcomes beyond traditional medical care. Social determinants of health (SDoH) are these non-medical factors—such as access to food, stable housing, transportation, and utility services—that influence a person's overall health and treatment outcomes. By effectively addressing and coding these determinants, providers can enhance care while also accessing additional reimbursement opportunities. CMS Strategic Plan “The Centers for Medicare & Medicaid Services (CMS) infuses health equity in everything it does. CMS is working to advance health equity so that each person has a fair and just opportunity to attain their highest level of health regardless of their age, race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.” CMS wants to make sure that all individuals and families have access to quality healthcare. To do this CMS has to remove the barriers to healthcare and support and partner with providers to ensure that every person and family can access care they need. Starting in January 2024, CMS began offering coverage for HCPCS code G0136. This coverage allows providers to be reimbursed when they use a standardized, evidence-based SDoH risk assessment tool that evaluates crucial areas such as food insecurity, housing instability, transportation needs, and utility difficulties. To comply with G0136, providers must use validated tools that have been independently tested. The 2024 MPFS final rule specifies some approved tools, including: CMS Accountable Health Communities Tool Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE) Medicare Advantage Special Needs Population Health Risk Assessment The key is to find a tool suitable for your practice’s patient population while ensuring it meets CMS requirements. Documentation of the tool used in the patient record is also critical. Hospital Outpatient Quality Reporting Program (OQR) CMS is expanding its focus on SDoH beyond inpatient settings. The Hospital Outpatient Quality Reporting Program (OQR), a pay-for-reporting quality program, requires hospital outpatient departments to meet specific quality reporting requirements. Failure to do so results in a 2% reduction in their annual payment update. CMS is proposing to adopt the screening of Social Drivers of Health measure, with voluntary reporting starting in CY 2025, followed by mandatory reporting beginning in CY 2026. This expansion reflects CMS’s recognition of the importance of social factors in shaping health outcomes. It provides healthcare providers with the tools to identify at-risk populations and develop targeted interventions. The Commitment to Health Equity measure further encourages healthcare organizations to integrate equity into their strategic and operational goals, fostering a culture of accountability and continuous improvement. Expanded Reimbursement Opportunities CMS is committed to advancing health equity and has included measures to support providers and hospitals in addressing social drivers of health. For example, the new policy finalized for FY 2024 recognizes the higher costs that hospitals face when treating patients experiencing homelessness or housing insecurity. This policy introduces new codes effective from October 1, 2024, which will be classified as complications or comorbidities (CCs), thus increasing reimbursement for specific diagnosis-related groups (DRGs). These codes include: Z59.10 (Inadequate housing, unspecified) Z59.11 (Inadequate housing, environmental temperature) Z59.12 (Inadequate housing, utilities) Z59.19 (Other inadequate housing) Z59.811 (Housing instability, housed with risk of homelessness) Z59.812 (Housing instability, housed, homelessness in past 12 months) Z59.819 (Housing instability, housed, unspecified) Real-World Scenarios: How SDoH Coding Can Make a Difference Here are some examples where documenting SDoH impacts patient care and enhances reimbursement: A patient is diagnosed with hypothermia, and the physician documents that their home does not have heating. Code: Z59.11 (Lack of heating). A child’s record shows a history of food insecurity due to financial difficulties at home, leading to hunger. Code: Z59.48 (Lack of food). A patient misses multiple appointments due to transportation issues. Code: Z59.82 (Lack of transportation). A patient becomes homeless following the foreclosure of their home. Code: Z59.819 (Housing instability). Why This Matters for Your Practice Incorporating SDoH documentation not only improves patient care but also opens up significant reimbursement opportunities. UASI is here to guide you through these changes and help your practice implement these assessments seamlessly. Our expertise ensures your compliance with the latest CMS guidelines, helping you maximize reimbursement potential while enhancing patient outcomes.  Take Action Today Don’t let your practice fall behind in leveraging these opportunities. Contact UASI to learn how our clinical documentation and coding solutions can empower your practice to succeed. Together, we’ll build a more equitable, efficient, and effective healthcare environment for your patients.

Fee-for-Service (FFS) vs. Value-Based Care (VBC): Understanding the Shift in Healthcare Compensation Models

When you think about coding in your organization, do you consider it a cost center? Often, the direct costs such as salaries, benefits, and equipment dominate the conversation. But what if we shifted the focus to understanding coding as an essential investment in your healthcare operations rather than just another expense? Beyond the Obvious Costs: The Hidden Impact of Coding We often focus on direct costs, but it’s easy to underestimate the indirect ones that quietly accumulate. Supervisory time, for example, is often overlooked as an indirect cost. Recruiting, testing, and turnover contribute further, along with quality assurance, ongoing education, and training. With every regulatory change and code-specific nuance, the demands increase—requiring more time, resources, and money. These factors don’t just affect your bottom line; they can significantly impact your Return on Investment (ROI) in ways that are frequently underestimated. The Real ROI of Accurate Coding The accuracy of your coding has a direct influence on your organization's financial health. Consider this: what would a mere 1% increase in coding accuracy mean for your top line? Not only could it boost revenue, but it could also reduce re-work costs and significantly cut down on denials. A lower denial rate means faster cash flow, less time spent on rework, and fewer headaches. Many systems often handle coding internally, focusing only on the direct costs. However, this approach overlooks not only the significant indirect costs—like supervisory time and training—but, more importantly, the impact on accuracy and productivity. These hidden factors can make a big difference in overall performance, which is why outsourcing your coding can provide a more efficient and accurate solution.  *“If you are questioning to remain in-house or outsource, it is imperative that you consider all costs and rewards – coding was costing me about $400k per month in lost revenue due to improper coding and lost charges (on $116m gross revenue, now $230m, so it would be higher).” Shifting Focus: From Administration to Patient Care What if your team could focus on what really matters—patient care—without the administrative burden of coding? Imagine the impact on your organization if you could shift the focus from managing coding staff and processes to enhancing patient outcomes. 6 Key Reasons to Outsource Your Coding Outsourcing your coding might be the game-changer your organization needs. Here’s why: Coder Shortage: The ongoing shortage of experienced coders, exacerbated by factors like ICD-10 implementation and the COVID-19 pandemic, makes finding and retaining qualified staff increasingly difficult. Quality and Productivity Demands: With evolving healthcare technology and constant regulatory changes, coding has become more complex. Meeting productivity and quality standards is challenging, especially for in-house teams. Fluctuating Workloads: Your coding needs fluctuate, but your costs don’t have to. Outsourcing allows you to scale up or down based on demand, saving you from the expenses of overstaffing or temporary hires. Geographical Challenges: Whether you're in a rural area or an underserved urban zone, outsourcing circumvents the difficulties of local recruitment by offering a broader talent pool. Improved Data Outcomes: Accurate and efficient coding is crucial for improving key data metrics that impact your organization’s reputation and reimbursement. By outsourcing your coding, you can enhance outcomes related to Health Grades, Quality Scores, CMS Star Ratings, and Risk Adjustment Factor (RAF) scores. Financial Relief: Outsourcing reduces the burden of managing an internal coding department. It cuts costs associated with recruitment, education, training, and retention, allowing you to focus resources where needed—patient care—and improves your overall ROI. *“We know it takes at least 18 months to get a coder proficient and accurate. I know our cost of labor is extremely high and would cost us considerably more per FTE when opportunity costs are calculated (lost revenue due to coding errors, missed charges, education, CDI, etc.)” Challenges and Opportunities: Beyond Just Numbers It’s not only about costs. The workforce is changing, and managing people is becoming harder. Burnout among coding staff is real, and it’s a growing concern that impacts both productivity and quality. Additionally, the coding workforce is aging, with many experienced coders approaching retirement. This looming wave of retirements is likely to exacerbate existing staffing challenges, making it even more difficult to maintain a fully staffed and skilled team. Continuous learning and development aren’t just nice-to-haves—they’re critical to success. As the demands on your coding team increase, are your leaders equipped to manage these challenges? UASI’s Solution: Experience and Expertise at Your Service This is where UASI comes in. With over 40 years of experience, we’ve honed our processes to deliver better results at the same or even lower cost than maintaining an in-house team. Here’s how we can transform your operations: • Reduced Headaches: We take on the challenges of recruiting, training, and managing coding staff, so you don’t have to. • Flexibility and Expertise on Demand: We provide the expertise you need when you need it, allowing you to scale up or down based on your coding demands. • Shared Success: We work as partners, with a focus on shared success and accountability. • Focus on What Matters: Our services free up your team to focus on patient care, reducing in-house tension and administrative strain. Highlighting the Benefits of Outsourcing Coding *“With a coding outsource, organizations do not need to spend money, time, and resources in hiring, training, and retaining experienced coders. Outsourcing is a cost-effective solution to reducing an organization’s administrative costs, as well as decreasing the administrative strain in the HIM department. In consideration of a coding outsource, it’s important to develop a cost-benefit analysis as well as determining appropriate, reportable KPIs.” “As I make changes to the RCM, one constant will be UASI because of their expertise and because of how they work with everyone on my side to effectively train my staff and to educate my providers.” Proven Outcomes: A Client Success Story Outsourcing of coding services has shown remarkable outcomes in terms of improved efficiencies and financial performance. Here are some notable results from a specific outsourcing client: • Decrease in DNFB by 44% in 90 days • Decrease in DNFC by 64% in 90 days • Nearly 100% decrease in front-end claim edits, with coders resolving edits concurrently at the time of coding, leading to an increase in clean claims being released for billing sooner. • Increased productivity, with all coders meeting or exceeding established productivity standards. • Improved efficiency of the organization’s HIM staff, allowing them to focus on resolving EMR issues, obtaining needed provider documentation, addressing chargemaster issues, and other registration and billing challenges. Outsourcing guarantees a qualified team to manage and perform the daily work associated with all coding needs, leading to measurable outcomes like improved DNFC and DNFB, enhanced coding quality, decreased coding edits, reduced denials, improved cash flow, and overall increased departmental efficiency. Flexible Engagement Models: Designed for Your Success At UASI, we offer two flexible ways to engage with our services: • Monthly Subscription Fee to Shared Success Fee: We start with a straightforward monthly subscription, transitioning to a shared success fee model after six months. This approach allows for a seamless transition to outsourcing, where we can re-badge your existing staff where appropriate. After the initial period, we evaluate the success of the engagement, ensuring it aligns with your goals and expectations. • Quick Results and Strategic Planning: Our model enables you to take quick action and see results rapidly. We begin with a thorough assessment to identify potential opportunities, propose a combination of a monthly fee and a shared success model, and allow your health system to evaluate the program for optimization. This data-driven approach ensures that you can determine the best path forward based on both strategy and measurable outcomes. These flexible engagement models are crafted to provide immediate benefits while allowing you to refine your strategy over time. By partnering with UASI, you can be confident in a solution that meets your organization's specific needs, enabling you to focus on what matters most—delivering exceptional patient care while achieving financial success. *CEO, West Coast Health System

“Out of Sight, Out of Mind” - A Cautionary Note for Hospitals Reducing Their Value-Based Care (VBC) Patient Populations

Burnout in healthcare is a significant and growing issue, affecting everyone from frontline clinical staff to administrative personnel. Despite ongoing efforts to tackle this challenge, burnout remains alarmingly high among physicians. According to the 2024 Medscape Physician Burnout & Depression Report, 49% of physicians are experiencing burnout, a modest improvement from the previous year’s 53%. This underscores the lingering impact of COVID-19 and the heightened pressures within the healthcare system. Healthcare practices are juggling Fee-For-Service (FFS) and Value-Based Care (VBC) models simultaneously. This means that there is either one generalized process that effectively serves both models or two distinct processes, rules, tools, and approaches. The FFS model pushes providers to see more patients and perform more procedures, which can be overwhelming and lead to unnecessary services. On the other hand, VBC emphasizes quality care and chronic disease management over the long term, requiring various management methods beyond traditional encounters. Balancing these models and meeting compliance demands can be daunting and contribute to burnout. Top 5 Strategies You Can Implement Now to Reduce Burnout 1. Simplify Administrative Tasks: Reducing bureaucratic tasks like charting and paperwork by employing Clinical Documentation Integrity (CDI) and coding professionals allows providers to focus more on patient care and less on administrative duties. Organizations that utilize CDI professionals reduce denials, re-work, and improve the effectiveness of their queries. This reduces the administrative burden not only for physicians but also for CDI and coding professionals. 2. Proactive Scheduling of Patients: Prioritizing Annual Wellness Visits (AWVs) and transitional care visits using Risk Adjustment Factor (RAF) scores, or Hierarchical Condition Categories (HCCs) helps manage resources efficiently and reduces provider burnout. Using data to understand current RAF scores and recapture opportunities by patient ensures that the patients with the most impact are seen at least annually and given their chronic conditions, more frequently as appropriate. 3. Conduct Prospective CDI Reviews: Ensuring CDI professionals prospectively review records and communicate priority clinical indicators guarantees accurate medical documentation, reduces the time providers spend researching patient records in advance, and ensures optimal outcomes while reducing re-work. 4. Effective Use of Coders: Utilizing professional coders to handle diagnosis codes for claims reduces compliance issues, lost revenue due to over-coding or under-coding, and increased frustration. A streamlined coding process ensures that claims are processed expeditiously, resulting in faster cash flow. This not only saves time but also reduces compliance risks and the administrative burden on physicians. 5. Leverage Technology: Implementing advanced technology solutions, such as our proprietary software RAF Vue™️ , can significantly enhance efficiency and accuracy. Instant insights into chronic code capture and recapture opportunities allow for quick identification of patients with the greatest treatment and financial impacts. With a centralized, patient-level view and automatic calculation of reported and potential RAF scores, RAF Vue™️ generates comprehensive reporting at the patient, provider, and reviewer levels. Best of all, RAF Vue™️ can achieve immediate go-live without requiring EMR integration, reducing the technological burden on your practice. Comprehensive Support from UASI At UASI, we specialize in guiding healthcare organizations through the intricacies of risk adjustment and value-based care. We evaluate programs, assess needs, identify priorities, and create effective strategies to reduce administrative burdens, enhance care quality, and improve financial outcomes. Our goal is to support your practice in reducing burnout and improving patient care. Let us help you navigate the complexities of risk adjustment and value-based care to achieve sustainable success. Contact us today to learn how we can support your practice in reducing burnout and improving patient care.

Our HCC experts Nancy Koors, Vice President of Corporate Development and Mary Stanfill, MBI, RHIA, CCS, CCS-P, FAHIMA, Vice President of Consulting Services recently teamed up with Colleen White, MSM, BSN, RN, CPC, Ambulatory CDI Program Manager at ChristianaCare, for a webinar discussing Successful HCC Risk-Adjusted Programs: Tactics to Manage Your Risk-Adjusted Population. ChristianaCare is featured on the World’s Best Hospitals 2022 list by Newsweek and among America’s 50 Best Hospitals 2022 according to Healthgrades. The webinar primarily focused on UASI’s Risk Adjustment Maturity Model and its four phases: Explore, Define, Implement, and Optimize, as well as lessons learned from ChristianaCare as they progressed through each phase. Here is a breakdown of each phase. Keep reading to find out in what phase your organization is. Explore: An organization is aware that they have a growing risk-adjusted patient population, but they may or may not know how many patient lives they are managing or their RAF scores. Whether they know their RAF Scores or not, they probably realize that their scores are not a true reflection of the health of their population. There are a lot of uncertainties in this phase such as: How accurate is our documentation? How do we analyze the sheer volume of patients and visits? Where do we start? How do we prioritize? A reactive approach to the explore phase is driven by reimbursement not reflecting the care provided. Define: The facility begins reviewing their risk adjusted patients to identify which patients do not have accurate RAF Scores. Based on this, the facility will prioritize patients for review to ensure the time spent is most productive. Typically, organizations begin to use Excel to manage the work queues. This can work early in the process, but as the patient volume increases and workflow begins to include other areas of the health system, it becomes problematic as the amount of data is difficult to manage and manual data entry becomes less reliable. The facility typically finds a chronic condition to focus on or a group of physicians to run a pilot test to determine the right people, processes, and tools needed. Implement: The hospital has moved beyond a pilot test and begins to implement a program where consistent procedures are followed across multiple clinics or provider groups. The team typically grows and the workflow becomes the norm. A cross-training program might exist for their growing team. More sophisticated tools are sought to replace Excel. Optimize: At this point the hospital has established a program with consistent policies and procedures. Performance is monitored, and they have been able to solve some of the easier issues such as recapturing previously identified HCCs year to year. The next step is to ensure they have captured the chronic conditions for their patients that have not been previously reported. Trends in chronic conditions will be analyzed and compared within their region. Data analytics and reporting become critical at this phase so that the health system can easily prioritize their work. If you are interested in finding out where you are in the process of managing your risk-adjusted population, take our 3-Minute Risk Adjustment Checkup . You can also download a white paper covering insights for managing HCCs and risk-adjusted populations on our website.

Change can be a daunting endeavor. When Pam Stence, Director of CDI for Sharp HealthCare, had a hunch that her CDI program may not be performing as well as it could, she decided to dig deep to find answers. She worked with her executive team and did research into key industry players like Cedars Sinai, Johns Hopkins, and U.S. News and World Report hospital data as a place to start benchmarking and comparing her own program’s data. This led her to the conclusion that she needed to optimize her program and rethink their performance. Pam knew that she could increase Complication/Comorbid Condition (CC) and Major Complication/Comorbid Condition (MCC) capture rates from 3M but needed to make changes to their CDI staffing plan to get the impact she needed. Over the course of two months, she worked with her internal team to establish a goal of 2.5 cases per hour and review 90% of all DRG payors. Coverage felt like a core issue. She needed the expertise and staff to get the job done. Pam was able to use her research to develop a strong case for the needed changes with her management team in order to bring her vision for her department to life. Hiring posed an interesting problem and was not something that could be quickly scaled. New hires could take up to a year to be trained and ramp up fully into their work load. Pam recognized that they needed quality resources quickly to hit their goals and would need an external partner. She established a list of mandatories they needed: A partner – not a vendor High quality resources Staff with the right credentials and experience Training in 3M 360 and Cerner Responsive Willing to be flexible to meet needs Known entity with previous engagement She turned to UASI for a solution. UASI assessed staffing needs, fully staffed up and scaled production quickly. Sharp was able review 90% of all their DRG payors within 1 year as opposed to the 60% rate the years prior. Currently, they review 98% of DRG payors and 90% of all payors at 48 hours. Sharp would hit $19M in 2023 in query impact, up from $11M the previous fiscal year. These were dollars that could have been left on the table had Pam not acted. Quality scores also improved. We asked Pam what her advice would be to other teams who recognize that they need to make changes to their CDI programs. She came up with great tips to make digging into change easier. Develop a strategic partnership with your vendor Share data and be transparent Be open to a new process Look at the benchmark data and be objective on where you stand; reach out for help if you need it Improve physician engagement, involvement and query responsiveness

1. The ongoing shortage of experienced coders is hitting your organization. Knowledgeable, experienced coders have long been in demand – but between the implementation of ICD-10 and the COVID-19 pandemic, the situation has become more complex than ever. Coding has become exceptionally complex – especially in places like CAHs, whose coders must cross-train to work across multiple specialty areas without interruption. And with fewer people than ever enrolling in coder education and certification programs, the shortage shows no signs of subsiding. Especially in today’s environment of coder scarcity, smart coding service providers employ recruiters dedicated specifically to coding professionals. They will operate at a scale that enables them to pay their coders a high hourly wage without forcing unusually high charges onto their clients. They’ll have programs in place to retain existing staff. And they’ll maintain a pipeline of talent for future needs, as well. 2. Your coders face ever-increasing quality and productivity demands. As healthcare technology evolves, so does coding complexity – especially in high-risk and specialty areas. Likewise, when healthcare systems acquire physician practices, they often find themselves with new professional fee coding responsibilities that their coders may not have the experience to manage. Then, there’s the question of assuring productivity and quality. When coders fall below expected quality and productivity levels, organizations find themselves with an impossible choice: Keep the coder but risk speed, accuracy, and even compliance issues. Or, terminate the coder and face the consequences of working short-staffed. An excellent coding partner will have a proven approach for vetting prospective coders. Equally important, they’ll provide continual professional development and testing to keep their coders sharp. That training and education will both reinforce existing processes and bring their coders up to speed with the latest demands of multiple types of healthcare organizations. They’ll conduct quarterly reviews and have specific action plans for consistently maintaining high standards. Accurate, defensible, compliant coding is essential to the revenue cycle of all healthcare organizations. That level of coding demands experienced, knowledgeable, high-integrity coders. Yet, many organizations – especially Critical Access Hospitals (CAHs) – struggle with this crucial capability. Outsourced coding isn’t the right solution for every organization. So, how do you know if it’s right for yours? Consider the following five essential reasons to pursue an outsourced solution: 3. Your coding load rises and falls – and it’s costing you money. Healthcare organizations often struggle with the expense of excess staffing during periods of low demand – whether because they employ extraneous coders during times of low demand or because they spend money on temporary coders in times of high demand. Those temporary coder costs go well beyond their hourly rates, too -- including what it takes to bring their institutional knowledge up to speed, integrate them into the organization, and ensure quality control. There is significant value in a coding partner who takes the time to learn the ebbs and flows of your coding load and your overall corporate culture. That knowledge enables them to scale up and down with your coding requirement, providing virtually instantaneous coverage when you need it – and keeping you from having to pay for coders when demand is low. They’ll also take the time to understand how your organization and department operate and prepare their coding professionals to fit in seamlessly. 4. You’re located in a rural or underserved urban zone. Many healthcare organizations require staff to live within their geographic area – even if those staff members are permitted to work remotely. As a result, issues ranging from infrastructure and education quality to safety make it difficult to attract and retain qualified coding talent. In an outsourced coding partnership, the coders are the partner’s employees, so they may not be bound by your organization’s residency requirements. However, your agreement with them can ensure full coding support, on-site and off-site, wherever you may be. 5. The expenses and stresses of an internal coding department are a burden. Increasing costs and decreasing reimbursements are challenging virtually every healthcare system. However, when you add in the costs of recruiting, hiring, onboarding, training, continuing education, and retention of an internal coding department, the financial burden can become overwhelming. When you outsource your coding to the right partner, you don’t spend time, money, and resources on building and maintaining an internal team of coders, ensuring quality, productivity, compliance, and even the software coders must use. The partner takes responsibility for those elements, which reduces your burden significantly. Many healthcare organizations are struggling with some or all of the challenges that may impede the consistent coding excellence necessary to achieve successful revenues. If yours is one of them, you owe it to your balance sheet to consider the advantages of the right outsourced coding partnership. About UASI UASI is the leading independent national provider of revenue cycle solutions designed to help healthcare facilities achieve accurate reimbursement in the quickest possible time.