Mar 11, 2024 | Uncategorized
Change Healthcare, a leading U.S. health technology company, is making strides in recovering from a ransomware attack it experienced in February. The attack, attributed to the ALPHV ransomware group, disrupted crucial operations, causing billing delays and raising security concerns across the healthcare sector.
After paying a reported $22 million ransom, Change Healthcare is gradually restoring its services. Electronic prescription systems, including Rx Connect, Rx Edit, and Rx Assist, are now operational, with full functionality in electronic prescribing, claim submission, and payment transmission.
The attack’s impact extended beyond Change Healthcare, affecting hospitals, doctors, and pharmacies, leading to cash flow issues. To mitigate these challenges, the U.S. Department of Health and Human Services (HHS) eased Medicare rules, allowing affected stakeholders to claim advance funding.
UnitedHealth Group introduced a temporary iEDI claim submission system to assist clients during the service disruption. Meanwhile, ALPHV, the ransomware group responsible for the attack, appears to be winding down its operations amid suspicions of an exit scam, though law enforcement agencies deny involvement.
The incident underscores the critical need for robust cybersecurity measures in the healthcare sector to safeguard patient data and ensure the uninterrupted delivery of care. As Change Healthcare and the industry recover from the attack, proactive security measures will be essential to mitigate future threats and uphold the integrity of healthcare systems.
The severity of the situation is underscored by reports from the American Hospital Association (AHA), indicating that hospitals are experiencing challenges in various facets of their operations. Processing claims, billing patients, and verifying insurance coverage have been hampered, potentially jeopardizing patient care and the financial stability of healthcare facilities.
The ripple effects of this cyberattack extend beyond immediate inconveniences. Health systems are grappling with an array of issues, including difficulties in verifying patient eligibility, communicating pharmacy prescriptions, and maintaining normal cash flow to sustain operations. The incident highlights the vulnerability of the healthcare sector to ransomware attacks, which have been on the rise in recent years, posing a significant threat to patient privacy and safety.
As the investigation unfolds, concerns persist about the potential long-term repercussions of the attack. While efforts are underway to contain the breach, the incident serves as a stark reminder of the critical importance of cybersecurity in healthcare. Organizations like Welter Healthcare Partners emphasize the need for robust security measures and regular staff training to mitigate the risk of cyber threats such as phishing attacks. As the healthcare industry continues to digitize and rely on technology for essential services, safeguarding patient data and ensuring the integrity of healthcare systems remain paramount priorities.
Feb 29, 2024 | Uncategorized
The demand for efficiency, precision, and a personal touch is high in the healthcare field. Welter Healthcare Partners recognizes the significance of blending personal support with technological innovation in today’s business of healthcare landscape. This philosophy underscores our commitment to prioritizing “High Touch & High Technology” in all facets of our services, particularly in our approach to credentialing and coding.
Credentialing is a complex process ensuring healthcare professionals meet qualifications and standards essential for delivering safe and high-quality care. This goes beyond ‘checking the boxes’. It serves as a cornerstone for patient safety and excellent service. WHP leverages our proficiency, streamlined processes, and adherence to regulatory standards to facilitate swift and cost-effective credentialing.
However, what truly distinguishes us is our dedication to fostering genuine human connections. In an age dominated by automated systems and algorithms, we recognize the irreplaceable power of human interaction. Each client account at Welter Health Partners is entrusted to a seasoned and knowledgeable team member. This ensures a personalized touchpoint for addressing concerns and providing expert guidance.
This personalized approach is more than just convenience; it revolutionizes the experience for our clients. With a real person readily available to address queries and resolve issues, we ensure greater accuracy in our work. This also mitigates billing denials! Our clients find reassurance in the knowledge that their needs are promptly attended to, leading to smoother operations and superior outcomes. For over three decades, Welter Health Partners has empowered physician practices, healthcare providers, and organizations across specialties to navigate the intricate landscape of the business of healthcare with success. Our hands-on methodology, coupled with our extensive expertise and technology, enables clients to focus on their core mission: delivering exceptional patient care.
Feb 12, 2024 | Uncategorized
In the world of revenue cycle management, the recent finalization of the CMS rule has sparked intense scrutiny. At Welter Healthcare Partners, we’re diving into its intricacies to understand how it affects individuals, organizations, and most importantly, our valued clients.
Assessing the Impact CMS Rule on Revenue Cycle Management
How Will This Affect Us?
With the CMS rule now in effect, it’s crucial to examine how it will reshape our daily billing operations, influence cash flow, and impact our budget.
A Positive Shift for Providers, Patients, and Billing Companies via the CMS Rule on Revenue Cycle Management:
Despite its focus solely on CMS payers and exclusion of commercial health plans, the new legislation represents a significant step forward. While it may not address all prior authorization challenges, it introduces provisions that promise benefits for providers, patients, and third-party billing companies alike.
Key Changes in Prior Authorization Process:
CMS has established clear timelines for payer decision-making on prior authorizations:
- Urgent requests: Must be addressed within 72 hours
- Standard requests: Decision required within 7 calendar days
Additionally, payers must now provide specific denial reasons, offering transparency and accountability in the prior authorization process. This structured communication is poised to enhance efficiency and predictability for all stakeholders.
Compliance:
Adhering to the new rules, especially regarding decision-making timelines for prior authorizations, is crucial. Third-party billing companies must ensure compliance to avoid penalties, maintain positive relationships with healthcare stakeholders, and assure clients of a seamless healthcare ecosystem interaction.
WHP is Ready for the Challenge!
While the upcoming changes necessitate investments in technology upgrades and unwavering commitment to compliance, the benefits are substantial. Quicker turnaround times for prior authorizations, increased transparency, and improved data exchange are poised to create a more efficient revenue cycle for our clients.
At Welter Healthcare Partners, we embrace these changes, ensuring seamless transitions for our clients. As we navigate evolving regulations and technology standards, our commitment to adaptability remains unwavering. Rest assured, we stand vigilant, ready to implement any necessary adjustments and uphold industry best practices, ensuring a wonderful experience for our clients in the ever-evolving healthcare landscape.
Feb 5, 2024 | Uncategorized
If you’ve ever worked with healthcare costs and insurance, you’re likely familiar with the term “risk adjustment coding.” But what does it entail, and why is it a critical component for both healthcare organizations and insurance companies? In essence, this serves as a mechanism to ensure accurate accounting for the health status of patients and to adjust payments accordingly.
Risk Score for Patients
The intricate process of risk adjustment coding involves healthcare providers using diagnostic codes to denote various aspects of a patient’s health, including age, sex, and any pre-existing conditions. These codes collectively formulate a “risk score” for each patient, estimating the probable cost of providing care over the year. Insurance companies then use these risk scores to modify payments to providers, ensuring that those treating sicker patients are compensated adequately compared to those handling healthier individuals.
Risk Adjustment Coding System
At its core, risk adjustment coding acknowledges that some patients naturally incur higher treatment costs. This could be due to pre-existing conditions or other health factors. This system helps prevent unfair penalization of patients by insurance companies and ensures that healthcare providers receive appropriate reimbursement for the care they deliver.
Risk Adjustment is a Safeguard
Risk adjustment coding safeguards patients from potential denial of coverage or exorbitant premiums based on pre-existing conditions. This ensures that individuals, irrespective of their health status, have access to the necessary care. Simultaneously, risk adjustment coding is pivotal for healthcare providers, particularly those catering to higher-risk patients. Without accurate coding, providers may face unfair penalties from insurance companies, jeopardizing their ability to maintain their practice and deliver high-quality care.
Crucial to Patient Care
Risk adjustment coding is an important component of the healthcare system. It guarantees that patients receive the care they require and that healthcare providers are fairly reimbursed for their services. Understanding the intricacies of risk adjustment coding sheds light on its importance in maintaining a balanced and just healthcare ecosystem.
Jan 30, 2024 | Uncategorized
In a groundbreaking move, the Centers for Medicare & Medicaid Services (CMS) has recently implemented a final rule, led by Administrator Chiquita Brooks-LaSure, that promises to revolutionize the prior authorization process. These reforms, aimed at cutting patient care delays and streamlining the process for physicians, are anticipated to result in substantial savings of $15 billion over the next decade. At Welter Healthcare Partners, we applaud these significant strides towards improving the healthcare landscape and recognize the positive impact they will have on both patients and healthcare providers.
Prior Authorization Reforms:
The final rule addresses prior authorization for medical services across various government-regulated health plans, including Medicare Advantage, State Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on federally facilitated exchanges. This comprehensive approach reflects a commitment to tackling challenges across different sectors of the healthcare system.
Technological and Operational Enhancements:
One of the key highlights of the reforms is the incorporation of an electronic prior authorization process embedded within physicians’ electronic health records. This transformative change is set to bring much-needed automation and efficiency to a previously time-consuming and manual workflow. We appreciate CMS for recognizing the importance of embracing technology to streamline processes and enhance the overall quality of patient care.
Enhanced Transparency and Patient Empowerment:
The administration’s action not only focuses on efficiency but also aims to enhance transparency around prior authorization. By requiring specific denial reasons, public reporting of program metrics, and making prior authorization information available to patients, the reforms empower individuals to make informed decisions about their healthcare. This marks a crucial step towards fostering a more patient-centric healthcare system.
Shortened Processing Time Frames:
CMS’s mandate for shortened processing time frames is a noteworthy aspect of the reforms. Starting in 2026, affected payers will be required to send prior authorization decisions within 72 hours for urgent requests and within a week for nonurgent requests. This commitment to faster response times aligns with the urgency of providing timely and essential care to patients.
Physician Advocacy and Potential Legislative Impact:
The collaboration between CMS and physician organizations, including the American Medical Association (AMA), showcases the power of advocacy in influencing positive change. The $15 billion estimated savings, coupled with the potential impact on the Improving Seniors’ Timely Access to Care Act, reinforces the significance of these reforms in shaping the future of healthcare legislation.
Addressing Concerns and Building a Better Future:
While payers argue that prior authorization is necessary for cost and quality control, physicians often highlight the adverse impact on patient care. The AMA’s survey findings underscore the urgent need for reform, with one-third of physicians reporting serious adverse events resulting from prior authorization protocols. The final rule is a crucial step towards addressing these concerns and creating a more efficient and patient-friendly healthcare environment.
At Welter Healthcare Partners, we recognize the monumental significance of CMS’s $15 billion victory for physicians in the realm of prior authorization. These reforms not only promise substantial financial savings but also signify a commitment to improving patient care, streamlining processes, and fostering transparency. As stakeholders in the healthcare industry, we look forward to witnessing the positive impact of these changes on both healthcare providers and the individuals they serve.
Read the original article here.
Jan 22, 2024 | Uncategorized
California Assemblyman Jim Wood has championed a groundbreaking bill, AB-815, aimed at simplifying the often cumbersome process of credentialing practitioners seeking to join healthcare plans. The bill proposes the establishment of a state board tasked with certifying private and public entities as delegated credentialing entities for health plans. Instead of health plans conducting their own credentialing, they would utilize the information provided by these certified entities.
The proposed state board is set to be a collaborative effort, comprising representatives from health plans, state health departments, physicians, and other healthcare providers. The goal is to have the board operational by July 1, 2024, with the application process for entities seeking certification expected to be in place by July 1, 2025. This move is poised to streamline the credentialing process, reducing redundancies and ensuring a more efficient and standardized approach.
The bill has already cleared the California Assembly and is now on its way to the senate for a vote, marking a significant step toward reforming the healthcare credentialing landscape in the state.
However, as the healthcare industry in various states grapples with evolving credentialing requirements, a broader perspective emerges. The landscape is rife with complex and dynamic regulations, often payer-focused, requiring meticulous attention from Credentialing Verification Organizations (CVOs). The insights shared by industry experts shed light on the nuanced challenges and opportunities within this realm.
One notable observation is the growing trend inspired by Arkansas, where states like California and West Virginia are considering or actively working towards creating or contracting with statewide CVOs. Arkansas has already set up a state-run CVO, and California is slated to accept applications in 2024 for a CVO to contract with. West Virginia has established provisions for contracting with a CVO but has not executed the plan as of yet.
This shift towards centralized credentialing entities indicates a recognition of the need for standardized, efficient processes that can navigate the intricacies of varying state requirements. As the healthcare industry continues to evolve, it becomes increasingly crucial for payers to stay ahead of these changes, ensuring compliance with state-specific mandates and optimizing the credentialing workflow.
California’s AB-815 signals a promising leap towards a more streamlined and efficient healthcare credentialing process. While challenges persist, the industry’s response, as seen in the pursuit of statewide CVOs, reflects a commitment to adaptability and improved operational efficiency. As the bill progresses through the legislative journey, it stands as a beacon of progress in the ongoing efforts to enhance the healthcare system’s effectiveness in California and potentially beyond.
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