Health Law Highlights

3 Ways AI Can Improve Revenue-Cycle Management

Summary of article from American Hospital Association:

The integration of artificial intelligence (AI) and automation can enhance revenue-cycle management (RCM) in healthcare, reducing costs and boosting efficiency. AI applications in RCM include automated coding and billing, predictive analytics for denial management, revenue forecasting, patient payment optimization, data security, and operational efficiency. Case studies demonstrate that AI can lead to significant improvements in RCM, such as reducing denials, increasing productivity, and improving financial outcomes. However, the adoption of AI also carries risks, requiring careful data structuring to prevent bias and validation of AI outputs. The adoption of AI in healthcare is expected to grow in the coming years, with initial focus on simpler tasks and gradually expanding to more complex aspects of RCM.


Local Physician and Practice Agree to Pay Over $2 Million to Settle False Claims Act Allegations

Press Release from U.S. Attorney’s Office, Eastern District of Michigan:

I don’t normally report on False Claims Act (FCA) matters from other states, but this one serves as a cautionary tale on “incident to” billing.

Under Medicare rules, covered services provided by non-physician practitioners (NPPs), like physician assistants, nurse practitioners, clinical nurse specialists, etc., are reimbursed at a reduced rate of 85 percent of the fee schedule amount.

The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for NPP services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).

Among other requirements, to bill a NPPs services as “incident to” the physician’s initial evaluation, the physician must provide direct supervision. Without direct supervision, the NPPs services must be billed under the NPPs provider number at the reduced rate.

Direct supervision in the office setting does not mean that the physician must be present in the same room, but the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Direct supervision in the home health setting, requires the physician to be physically present in the home to oversee the care.

In this reported FCA settlement, the NPP’s home health services were being billed “incident to” the physician’s services, but the physician was not physicially present in the home. Thus, the physican and his practice falsely claimed an extra 15% reimbursement on all those services.

The physician and his practice paid $2,003,800.91 to resolve the FCA allegations.

The moral of the story … know the rules about billing, and if you don’t, hire someone who does.

Health Law Highlights

Now in Effect: Texas Ends Surprise Bills for Ambulance Rides

From D Magazine, by Will Maddox:

Surprise medical billing has largely been eliminated due to federal and state legislative efforts, but ambulance billing was not included in these regulations. A new Texas law now prevents surprise bills for ambulance services for those with state health insurance plans.

Emergency physicians and anesthesiologists were the most common sources of surprise bills, with research indicating that one in four ambulance rides results in a surprise bill. Approximately 60% of ambulance providers, both private and public, are out of network.

Bipartisan State Bill 2476 prohibits out-of-network ambulance providers from sending patients surprise bills, requiring insurers to cover costs based on local rates set by counties and cities. If no local ambulance rate exists, insurers will pay the lesser of 325% of the Medicare reimbursement rate or the full billed charge.

The new bill simplifies the initial surprise bill process, which had led to numerous lawsuits filed by the Texas Medical Association challenging the process for settling a surprise bill as directed by the federal No Surprises Act.

The new rules only cover those on state healthcare plans, including state employees and teachers, approximately one in three Texans.