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Payer Behavior: Network Pool Restrictions
In 2023, more payers opted for narrower provider networks as a method of controlling costs than ever before. Not only does this lead to decreased overall satisfaction by patient members - but this can also cause delays in care with the potential to put patients in harms way.
According to a recent article in Consumer Reports, narrow network plans typically “have 25 percent or less of the physicians in the local area participating. The most restrictive plans have less than 10 percent of local doctors signed on.” Plans like these use restricted networks to ensure increased volume to a smaller number of approved providers, thus driving down cost. Private payers, ACA health exchanges, and Medicare Advantage are all capable of providing plans with such restrictions.
Furthermore, many Americans with narrow network plans do not realize they are under increased provider restrictions until after they have sought care. The article states that one in ten Americans were surprised to find out the healthcare provider they had elected to perform a service was not part of their network. Exacerbating this issue is the fact that a decreasing number of plans sold on the individual health insurance market offer any out-of-network coverage whatsoever - just 29% in 2018.
Read the full article here and learn more about HURC’s ability to optimize payer return.
RWJBarnabas Leans into Patient Experience Rounding
"Instead of waiting for patients to flag grievances in HCAHPS surveys, RWJBarnabas Health is going straight to the bedside to identify and solve patient experience issues in real time," Becker's Healthcare reports.
RWJBarnabas Health's new nurse rounding program allows for each unit's nurse leader to check in on patients in the morning. They can then direct patient needs to other staff, such as bedside nurses, if needed.
"The system also uses a software platform to track these issues to look for broader patient experience trends and areas of improvement," Dr. Andy Anderson, executive VP and chief medical and quality officer at RWJBarnabas, mentioned.
HURC is proud to work with RWJBarnabas Health to allow for initiatives like this to expand, refocusing care towards patients!
Revenue Cycle: Claims Denials & Payer Audits
“CentraCare Health has denials sitting out there for 300 days, creating administrative and financial burden, says rev cycle director.”
A recent article in Healthcare Finance News details how heavy reliance on AI algorithms to tackle claims processing can lead to privacy issues, inaccurate results, and complexities that divert focus from the patient.
HURC believes in empowering doctors and nurses to focus on elevating patient care. Our UR Services and Revenue Cycle Optimization Solutions have brought about denial coordination with rapid rule change adoption and specialized payer/provider communication & reconciliation to give providers the advantage.
HURC works with healthcare professionals to harness hospital systems' existing infrastructure, saving millions and bringing back the focus of care to what really matters: the patient.
Visit HURC.com for more information - and learn more about our approach as it pertains directly to Revenue Cycle here.
AI in Healthcare: Promises & Pitfalls
Where does AI fit into your healthcare encounter?
Do you trust AI to interpret your imaging results?
"In the context of accomplishing clinical tasks, trust in doctors using AI and in AI alone is higher for people who are familiar with AI. That said, it’s striking that even people who profess familiarity with AI place more trust in doctors alone than in doctors using AI – and this pattern becomes more pronounced as people consider the use of AI for diagnosis and treatment, not just interpreting images.
Again, there is a major opportunity to align perception with reality, as studies have documented the benefits of AI across a range of clinical and non-clinical healthcare tasks," a report about AI's promises and pitfalls by NRC Health explains.
Read the full report here.
AANP Spotlights Critical Health Care Trends
Ready to make 2024 the Year of Patient-Centered Healthcare?
The American Association of Nurse Practitioners lists five critical health trends that will impact the delivery of patient-centered health care in 2024 and beyond in the article.
As the nurse practitioner profession grows in demand, nurse practitioners will be able to be "at the forefront of change, consistently adapting to meet the dynamic needs of patients and their communities," said AANP President Stephen Ferrara, DNP, FAAN.
Healthcare IT Hits a Speed Bump
Kicking off your 2024 with an overview of where healthcare IT is projected to go in the new year, as well as some benefits and risks associated with it.
Bain & Company's Global Healthcare Private Equity Report describes how healthcare IT is emerging in revenue cycle management, clinical workflow optimization, and patient engagement. It also lists trends to note and key themes to watch out for in 2024.
"Given the speed at which HCIT is evolving, and the presence of new competitors, the importance of a clear fund strategy, integrated diligence, and ability to underwrite post-acquisition value creation levers will be ever more important in the near future."
Learn more here.
Payer Behavior: Rapid-Fire Policy Change
Every year, changes to Payer policies and regulations can number in the tens to hundreds of thousands. These changes are constant, sometimes seemingly arbitrary, and are often lacking in guidance. Ultimately, providers bare the burden of navigating this constantly changing landscape to ensure yield loss is discovered and minimized.
HURC can help. Learn more about HURC’s ability to optimize payer return here.
Payer Behavior: Automated Denials
the AI powered algorithm ‘nH Predict’, developed by naviHealth and leveraged by UnitedHealthcare and Cigna Healthcare, has yielded increased wrongful denials for member medical claims.
As a result, the organizations are currently facing a legal action filed in November of 2023. Cigna Group is also navigating litigation surrounding the wrongful denials of large batches of claims as a result of another automated claims review process called: PxDx.
Becker’s Healthcare reports that, “The lawsuit alleges the algorithm predicts how long a patient will need to remain in skilled nursing care and overrides physicians' determinations for the patient.” Optum, the care management company that acquired naviHealth in 2020 issued a statement saying, with regard to use of the nH Predict tool, “The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home. Coverage decisions are based on CMS coverage criteria and the terms of the member's plan. This lawsuit has no merit, and we will defend ourselves vigorously."
Read more here.
This news showcases the potential harm to patients as organizations seek to incorporate further automation and experiment with AI-driven algorithms - and highlights the benefits of partnership with an organization like HURC. With increased oversight on claims denials and embedded operators working alongside existing provider FTEs, HURC can identify and rectify wrongful claims generated by irresponsible and unethical automation in real-time.
Let HURC bridge the gap between payer and provider - allowing clinicians to focus on what matters most: the patient.
The Crushing Cost Of Tracking Healthcare Quality
One Hospital’s Story.
As the United States shifts from prioritizing fee-for-service reimbursement to value-based care, measuring the quality of care is becoming increasingly important. However, within our complex healthcare system, tracking quality is no easy feat.
The following article by Forbes calls for standardization in quality metrics. It describes how claims data, chart-abstracted data, and patient survey data are used to analyze quality, but how difficult, time-consuming, and costly it is for hospitals to make sense of the results from these different sources.
Learn more here.
House Price Transparency Legislation Passes
with bipartisan support.
"The Lower Costs, More Transparency Act, which advances policies to force pharmacy benefit managers and hospitals to meet price transparency standards, passed on the House floor Monday by a vote of 320 to 71," Fierce Healthcare reports.
The recent bill mandates that providers and PBMS list prices publicly before charging patients and increases funding toward community health centers in underserved communities to combat physician shortages.
Supporters of the bill claim that it will also aid in the shift from fee-for-service to value-based care when treating patients, as United States of Care CEO Natalie Davis says: “By demystifying hospital billing through transparency measures and protecting patients from facility fees, as 13 states have already done, we can take steps towards reducing the burden of healthcare costs and work towards a patient-first model that prioritizes quality over quantity."
Read more here.
Where are all the Nurses?
Hospitals, advocates disagree on crisis
"Without first fixing the workplace problems in U.S. hospitals, Franks said that any nurse recruitment efforts are essentially building on quicksand — they may get people in the door, but they lack the foundation to succeed."
Healthcare Dive's recent article takes a deep dive into America's current nursing shortage in hospitals. Covering everything from hospitals struggling to higher despite the nursing talent pool growing to how hospitals can win nurses back, the article discusses differences in viewpoints, causes for the shortage, and solutions for the future.
Learn more here.
Payer Behavior: Blurred Lines
the “Payvider”
In recent years, a concerning trend has emerged in the healthcare industry: payers are increasingly assuming the role of healthcare providers, often to the detriment of patients and quality of care. While the integration of insurance and healthcare services may seem beneficial in theory, it has led to a multitude of challenges that compromise the quality of care provided.
By exerting control over medical decisions and prioritizing cost reduction, insurance companies may hinder patient access to necessary treatments and limit the autonomy of healthcare providers. This shift blurs the line between insurers and caregivers, raising concerns about conflicts of interest and prioritization of profit over patient well-being. As insurance companies continue to expand their presence in the healthcare landscape, it is crucial to strike a balance that allows for affordable coverage without compromising the quality and integrity of patient care.
Let HURC bridge the gap between payer and provider - allowing clinicians to focus on what matters most: the patient.
Forbes: Top 10 Healthcare Predictions for 2024
Every year, Dr. Sachin H. Jain offers his forecast for the next year’s healthcare industry trends.
In his article recently published in Forbes, Dr. Jain posits and expands upon the below list of predictions:
Low Political Engagement on Health Policy Issues
More Mega-Mergers
The Disappearance of Healthcare Startups
Medicare Advantage Scrutiny
Closeted Industry Backlash against Health Equity Efforts
Continued Poor Clinician Morale
Increased Executive Turnover
Read the article here - and learn how HURC can help your provider organization navigate a tumultuous 2024.
New York Earmarks $500m for Proposed Cybersecurity Regulations
Recently, New York Governor Kathy Hochul announced tighter regulations on cybersecurity implementation for hospital systems, assigning $500 million toward the cause.
180+ hospitals across New York can apply for funding. The $500 million expenditure hopes to “spur investment in modernization of healthcare facilities as well as utilization of advanced clinical technologies, cybersecurity tools, electronic medical records, and other technological upgrades to improve quality of care, patient experience, accessibility, and efficiency,” according to the governor’s office.
Possible issues lie in ensuring that smaller hospital systems are able to combat ransomware attacks and adopt new regulations to the same extent as larger hospital systems with more money and staffing resources. The following article by Healthcare Brew shares more.
AI Risks? The Courts Decide.
“Many open questions remain on AI risks, liability that will likely play out in court, experts say”
A Fierce Healthcare article discusses President Biden's executive order on AI and the challenges that federal agencies are facing as a result. The executive order remains vague when it comes to standardization and liability of AI implementation, and the article includes executives from Searce Inc, Wolters Kluwer, MITRE, and more weighing in on how they plan to move forward within the context of the executive order.
Read more here.
AI and Clinical Practice
Recently, Editor in Chief of JAMA & the JAMA Network Kristen Bibbins-Domingo hosted Dr. Nigam H. Shah, MBBS, PhD - Stanford University, as part of the JAMA & AI Clinical Practice Series.
“I would argue that we all want the learning health system. We all want personalization in our care. And the core tenet of that is to learn from the prior experience of similar patients.”
Shah emphasized the importance of feeding Clinical AI Tools the “right diet” to ensure exceptional healthcare experience and the safety of the patient.
Read more on the JAMA Network and watch the discussion here.
UnitedHealth Sued over AI
UnitedHealth Group faces a potential class-action lawsuit over its use of an artificial intelligence tool to allegedly deny post-acute care coverage to Medicare Advantage members.
Contact Us today to learn more about HURC’s philosophy regarding automation implementation and leveraging AI.
Happy Veterans Day
To all veterans and families of those who have served, the entire country thanks you for your service and sacrifice. Happy Veterans Day!
Solving the Productivity Paradox: Healthcare
Spencer Dorn, Vice Chair & Professor of Medicine, UNC, offered his take on a recent New Yorker article as it pertains to healthcare.
On LinkedIn, Dorn posed the question: “Is the core problem with electronic health records that they myopically focus on individual tools rather than workflows?”
He postulates that, “This certainly rings true in healthcare, where individual clinicians struggle to keep pace with an endless barrage of electronic messages and tasks, the bulk of which could be at least partially handled by other teammates.”
HURC is uniquely poised to overcome the burdens placed upon clinicians - with the ultimate goal of empowering doctors and nurses to focus solely on patient care. Dorn ends his post by stating: “to sustain our workforce and provide better care – and especially if we hope to harness AI to automate tasks – we must reevaluate and reorganize our work.”
At HURC, we agree - and we’re poised to implement these solutions today. Read Dorn’s full post here - and Contact HURC today.