/ en Wed, 30 Jul 2025 14:04:08 -0500 Mon, 14 Jul 25 15:29:12 -0500 /standardsguidelines/2020-10-15-patient-billing-guidelines <div class="container"><div class="row"><div class="col-md-8"><h2>Patient Billing Guidelines</h2><h3>Approved by AHA Board of Trustees</h3><h3>April 20, 2020</h3><p><em>The mission of each and every hospital is to serve the health care needs of its community 24 hours a day, 7 days a week. Their task is to care and to cure. America’s hospitals and health systems are united in providing care based on the following principles:</em></p><ul><li><em>Treating all people equitably, with dignity, respect and compassion</em></li><li><em>Serving the emergency health care needs of all, regardless of a patient’s ability to pay</em></li><li><em>Assisting patients who cannot pay for part or all of the care they receive</em></li></ul><p><em>The following guidelines outline how all hospitals and health systems can best serve their patients and communities. They underscore hospitals’ commitment to ensuring that conversations about financial obligations do not impede care, while recognizing that determinations around financial assistance require mutual sharing of information by providers and patients. Additionally, they balance needed financial assistance for some patients with the hospital’s broader fiscal responsibilities in order to keep their doors open for all who may need care in a community.</em></p><p><em>These voluntary guidelines represent the AHA’s expectations of what the hospital and health system field can and should do to address issues of coverage, billing and debt collection, and accountability. The guidelines are largely adapted from what is already required in federal law for tax-exempt hospitals (*) and are intended to align with a core principle of universal coverage. Specifically, all individuals should have access to and ensure they are enrolled in a form of comprehensive health coverage as the primary mechanism for paying for care. Moreover, the guidelines are crafted to reflect the hospital field’s immense diversity. Hospitals will need to adapt these guidelines to the needs and expectations of their particular communities. Hospitals in some states may need to modify use of these guidelines to comply with state laws and regulations.</em></p><h2>Guidelines</h2><h3>Helping Patients Pay for Hospital Care</h3><h4>Helping Patients Qualify for Coverage</h4><ul><li>Hospitals should help uninsured patients identify potential sources of public and private coverage.</li><li>Hospitals should assist uninsured patients with submitting an application for coverage, or direct patients to other services and supports that can help them get enrolled.</li></ul><h4>Helping Patients Qualify for Financial Assistance</h4><ul><li>Hospitals should have a written financial assistance policy.<a href="#fn1">*</a></li><li>Hospitals’ financial assistance policy should describe when care may be free or discounted, and delineate eligibility criteria, the basis for determining a patient’s out-of-pocket responsibility and the method for applying for financial assistance.<a href="#fn1">*</a></li><li>Hospitals should communicate this information to patients in a way that is easy to understand, culturally appropriate and in the most prevalent languages used in their communities.<a href="#fn1">*</a></li><li>Hospitals should publicize their financial assistance policies broadly within the community served (e.g., post on the premises and on the website and/or distribute directly to patients) and share them with other organizations that assist people in need.<a href="#fn1">*</a></li></ul><h4>Providing Financial Assistance to Patients</h4><ul><li>Hospitals should create and adhere to a reasonable and compassionate policy that governs the free care for patients with the most limited means as defined by income below 200% of the federal poverty limit (FPL) combined with a level of assets appropriate for the community.</li><li>Hospitals should create and adhere to a reasonable and compassionate policy that governs the payment obligations for other patients of limited means up to a certain percentage of income and assets, or percentage of the FPL, as appropriate for the community, regardless of insurance status.</li><li>Hospitals should provide a reasonable discount when billing patients of limited means.<a href="#fn1">*</a></li><li>Hospitals should apply financial assistance policies consistently and fairly, without regard to race, ethnicity, gender, religion, etc.</li></ul><h3>Ensuring Fair Billing and Debt Collection Practices</h3><h4>Communicating Effectively with Patients</h4><ul><li>Hospitals should use a billing process that is clear, concise, accurate and patient friendly.</li><li>Hospitals should respond promptly to patients’ questions about their bills and requests for financial assistance.</li><li>Hospitals should provide financial counseling to patients to assist them in paying their bill, and make the availability of this counseling widely known.</li><li>Hospitals should have a written debt collection policy.<a href="#fn1">*</a></li><li>Hospitals should ensure that every effort is made to work together with patients to determine whether the individual is eligible for financial assistance before undertaking significant collections actions, and those efforts can include working with other organizations or entities that can help make the determination.<a href="#fn1">*</a></li><li>Hospitals’ written collections policies should include the actions that may be taken in the event of nonpayment and require an advance notice of at least 30 days to patients identifying the specific action(s) it intends to take, when the action will be initiated, and the availability of financial assistance.<a href="#fn1">*</a></li><li>Hospitals should ensure that staff members who work closely with patients are educated about hospital billing, financial assistance, and collection policies and practices.</li></ul><h4>Oversight of Third-party Debt Collection</h4><ul><li>Hospitals should require any contracted third-party debt collection company to be compliant with the Fair Debt Collection Practices Act.</li><li>Hospitals should require any contracted third-party debt collection company to meet key components of its collection policies as well as any legal requirements that would apply if the action were taken directly by the hospital.<a href="#fn1">*</a></li><li>Hospitals should require regular reports on debt collection efforts, including attestation of compliance with hospital policies and obligations.</li></ul><h4>Protecting Patients from Certain Debt Collection Practices</h4><ul><li>Hospitals’ billing and collection policy should forgo garnishment of wages, liens on a primary residence, applying interest to the debt, adverse credit reporting, or filing of a lawsuit unless the hospital has established that the individual is able but unwilling to pay.</li><li>Hospitals’ billing and collection policy should establish the minimum amounts owed that could lead to debt collection or filing of a lawsuit.</li><li>Hospitals should make multiple attempts to reach and negotiate with patients before proceeding to court action.</li></ul><h3>Ensuring Accountability</h3><h4>Approval of Financial Assistance and Debt Collection Policies</h4><ul><li>The hospital governing body should approve and annually review financial assistance and collection policies, as well as routinely review the status of hospital debt collection efforts.<a href="#fn1">*</a></li><li>The hospital leadership should continually review hospital policies and practices related to these guidelines to ensure they are best serving their patients and communities.</li></ul><hr><p id="fn1">*These guidelines are currently required in federal law for tax-exempt hospitals.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2020/10/Patient-Billing-Guidelines.pdf" target="_blank" title="Click here to download the Patient Billing Guidelines PDF."><img src="/sites/default/files/inline-images/Page-1-Patient-Billing-Guidelines.png" data-entity-uuid="72a53918-793c-43ea-8d9c-d1b20ce93d15" data-entity-type="file" alt="Patient Billing Guidelines page 1" width="1870" height="2420"></a></p><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2020/10/Patient-Billing-Guidelines.pdf" target="_blank" title="Click here to download the Patient Billing Guidelines PDF.">Download the Patient Billing Guidelines PDF</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/patient-billing-guidelines-affirmation" target="_blank" title="Click here to see how your hospital or health system can affirm the patient billing guidelines.">Affirm the AHA Patient Billing Guidelines</a></div><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/infographics/2022-08-18-hospitals-and-health-systems-affirming-aha-patient-billing-guidelines" target="_blank" title="AHA Members can click here to see how the hospitals and health systems who have already affirm the AHA Patient Billing Guidelines.">See Hospitals and Health Systems That Have Affirmed the Patient Billing Guidelines</a></div></div></div></div> Thu, 15 Oct 2020 08:05:12 -0500 Billing & Collections /news/headline/2025-07-14-district-court-vacates-rule-banning-medical-debt-credit-reports <p>The U.S. District Court for the Eastern District of Texas July 11 <a href="https://storage.courtlistener.com/recap/gov.uscourts.txed.235173/gov.uscourts.txed.235173.52.0_1.pdf" title="vacated ruling">vacated</a> a rule issued by the previous administration that would have banned medical bills from appearing on credit reports and prohibited lenders from using medical information in lending decisions. U.S. District Judge Sean Jordan said in the order that the rule exceeded the authority of the Consumer Financial Protection Bureau and violates the Fair Credit Reporting Act.</p> Mon, 14 Jul 2025 15:29:12 -0500 Billing & Collections /news/headline/2025-05-12-aha-makes-100-suggestions-trump-administration-providing-regulatory-relief <p>The AHA May 12 <a href="/lettercomment/2025-05-12-aha-response-omb-deregulation-rfi">responded</a> to the Office of Management and Budget's April 11 request for <a href="https://v">information</a> on regulatory relief, making 100 suggestions to the Trump administration to help reduce burden on hospitals and health systems. “The Trump administration has rightly pointed out that the health status of too many Americans does not reflect the greatness or wealth of our nation,” said AHA President and CEO Rick Pollack. “Excessive regulatory and administrative burdens are a key contributor, as they add unnecessary cost to the health care system, reduce patient access to care and stifle innovation.”  <br><br>The AHA’s recommendations fall under four categories: billing, payment and other administrative requirements; quality and patient safety; telehealth; and workforce. </p> Mon, 12 May 2025 15:12:50 -0500 Billing & Collections /lettercomment/2025-05-12-aha-response-omb-deregulation-rfi <p>May 12, 2025</p><table><tbody><tr><td>Honorable Robert F. Kennedy Jr. <br>Secretary<br>U.S. Department of Health and Human<br>200 Independence Ave SW<br>Washington, DC 2001<br> </td><td>Honorable Russell T. Vought<br>Director<br>Office of Management and Budget<br>725 17th Street NW<br>Washington, DC 202503</td></tr><tr><td>Honorable Mehmet Oz, M.D.<br>Administrator<br>Centers for Medicare & Medicaid Services<br>7500 Security Boulevard<br>Baltimore, MD 21244-1850</td><td> </td></tr></tbody></table><p><br><em><strong>RE: Request for Information: Deregulation (FR Doc. 2025-06316)</strong></em></p><p>Dear Secretary Kennedy, Administrator Oz and Director Vought:</p><p>On behalf of the ���������� Association’s (AHA) nearly 5,000 member hospitals, health systems and other health care organizations, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, we applaud you for seeking recommendations on how to free the health care system from burdensome administrative requirements that prevent Americans from accessing the care they need to live their healthiest lives.</p><p>The Trump administration has rightly pointed out that the health status of too many Americans does not reflect the greatness or wealth of our nation. Excessive regulatory and administrative burdens are a key contributor, as they add unnecessary cost to the health care system, reduce patient access to care and stifle innovation. </p><p>For example:</p><ul><li>More than a quarter of all health care spending goes to administrative tasks — topping more than $1 trillion annually.<sup>1</sup> Providers, in particular, face excessive costs to check patients’ eligibility for coverage, bill for payment, and process prior authorizations and appeals of coverage denials.</li><li>Hospitals and health systems spend billions of dollars annually just on collecting and submitting quality measures, with one survey estimating annual per-hospital costs of $3.5 to $12 million.<sup>2,3 </sup>The physicians with whom hospitals partner in delivering high-quality care face similarly daunting costs, with physicians in just four specialties — general internal medicine, family medicine, cardiology and orthopedics — spending an estimated $15.4 billion annually on quality measurement.<sup>4</sup></li><li>Prior authorization requests reached nearly 50 million in 2023 for Medicare Advantage beneficiaries alone, an increase from 42 million in 2022.<sup>5</sup></li><li>Most claims initially denied by insurers (70%) are ultimately paid, meaning a significant amount of administrative cost is a complete waste.<sup>6</sup></li><li>The Centers for Medicare & Medicaid Services (CMS) regulations restrict the ability of certain advanced practice providers to independently practice more than is allowable in some states, which are responsible for clinician licensure and scope of practice.</li></ul><p>Addressing unnecessary administrative burdens and costs would go a long way to not only lower health system costs but support the accessibility of care. Many hospitals are financially unstable, with nearly 40% operating with negative margins.<sup>7</sup> This has led to closures of services and even entire hospitals, and the resulting loss in access to care is felt by entire communities.</p><p>The AHA, therefore, enthusiastically shares its top 100 ways that the administration could reduce the burden on hospitals and health systems. To put together this list, the AHA collected more than 2,700 ideas from an AHA member survey. Hospitals across the country, along with our Board of Trustees and other member advisors, identified outdated, burdensome, duplicative and expensive regulations that do not improve quality and patient safety and, in some cases, impede hospitals’ ability to offer the highest quality, most efficient care. Many of the items here also would remove administrative complexity to ensure that health care workers spend their time on patients, not paperwork. Some of these suggestions will require partnership with Congress, but many will not. Enacting even half of them would make a real difference throughout the health care system.</p><p>Our recommendations are grouped into four categories:</p><ul><li>Billing, Payment and Other Administrative Requirements.</li><li>Quality and Patient Safety.</li><li>Telehealth.</li><li>Workforce.</li></ul><p>While the full list is attached, below are the top actions we urge the administration to consider in each area.</p><h2>BILLING, PAYMENT AND OTHER ADMINISTRATIVE REQUIREMENTS</h2><p>Research estimates that between 25-30% of all health care spending goes toward administrative tasks, not patient care.<sup>8</sup> These tasks include verifying patients’ insurance and coverage status, conducting prior authorizations, and acquiring and managing the personnel and technology to comply with different payment models and payer requirements. To reduce billing and payment-related burden, we recommend the following.</p><p><strong>Make all Center for Medicare and Medicaid (CMMI) models voluntary, and specifically the Transforming Episode Accountability Model (TEAM) (42 CFR 512.5) and repeal the mandatory Increasing Organ Transplant Access (IOTA) Model (42 CFR 512.412) and the Inpatient Rehabilitation Facility (IRF) Review Choice Demonstration.</strong> While we strongly support innovation to improve the quality and accessibility of health care at lower costs, some of the CMMI models, as designed, could have an immediate detrimental impact on the quality of care or on patients’ access to care by overburdening their providers.</p><p>The IOTA Model is a complex mandatory payment model that purports to test whether hospital performance-based incentive payments will increase access to kidney transplants; however, these payments are designed to incentivize volume, not quality, and, in doing so, could lead to lower quality transplants and thus a higher risk of failure.</p><p>The TEAM would mandate that over 740 acute care hospitals receive bundled payments for five types of surgical episodes, irrespective of whether the hospitals are able to implement the bundles and whether they will improve patient care. The model particularly targets hospitals with low levels of existing experience with alternative payment models, increasing the risk that participating in such a model could financially destabilize them, threatening access to care for everyone in the community.</p><p>Finally, under the IRF Review Choice Demonstration, IRFs will have 100% of their Traditional Medicare claims subject to unnecessary and onerous pre- or post-claim review for at least six months. This will add considerable staffing costs to providers who are already struggling under rising input costs and unstable revenue.</p><p><strong>Repeal the excessive, confusing and imbalanced provider disincentives included in the June 2024 final rule “21st Century Cures Act: Establishment of Disincentives for Health Care Providers That Have Committed Information Blocking” (RIN 0955-AA05).</strong> Under the final rule, hospitals and providers found to engage in information blocking may face reductions in Medicare payment updates, adjustments to reimbursement rates, lower performance scores and potential ineligibility for certain incentive programs. We believe in the importance of making critical health information available to patients, the clinicians treating those patients, and those with appropriate reasons for having access, among which are payment, care oversight and research. However, the disincentive structure in this rule is excessive, so much so that it may threaten the financial viability of economically fragile hospitals, including many small and rural hospitals. In addition, the processes by which the Office of the Inspector General will determine if information blocking has occurred are unclear, including the appeals process, giving this proposed rule the appearance of being arbitrary and capricious.</p><p><strong>Standardize more insurance-related administrative transactions, starting with operationalizing the Interoperability and Prior Authorization Final Rule (CMS-0057-F) to establish standard electronic prior authorization processes in Medicare Advantage, the Health Insurance Marketplaces and Medicaid. </strong>Hospitals often have hundreds if not thousands of contracts with different insurance plans. Each of these plans include different rules and processes, including the way to communicate requests and share associated documentation with plans (e.g. phone, fax, proprietary portal), the services that are subject to prior authorization, and the clinical criteria a plan will use to adjudicate prior authorization and coverage requests, among other things. There is tremendous opportunity to streamline many of these rules and processes to both improve patient’s access to care while also reducing the costs and burden on providers associated with compliance. For example, prior authorization is frequently applied inappropriately in ways that delay care and harm patients. CMS has taken significant steps to move many health plans towards standardized electronic prior authorization processes. These rules are intended to go into effect in 2026 and 2027, and we urge the administration to ensure robust and timely implementation.</p><h2>QUALITY AND PATIENT SAFETY</h2><p>High-quality, safe care is the core of hospitals’ missions. While many regulations originated out of an interest to improve care quality or patient safety, those same regulations, over time, have often become obsolete or redundant. Hospitals and health systems spend billions of dollars annually just on collecting and submitting quality measures, with one survey estimating annual per-hospital costs of $3.5 to $12 million.<sup>9,10</sup> The physicians with whom hospitals partner in delivering high-quality care face similarly daunting costs, with physicians in just four specialties — general internal medicine, family medicine, cardiology and orthopedics — spending an estimated $15.4 billion annually on quality measurement.<sup>11</sup> To reduce burdens related to quality measurement and reporting, we recommend the following.</p><p><strong>Repeal outdated COVID-19 reporting mandates.</strong> As noted above, data reporting is an incredibly time intensive activity that pulls clinicians away from patients and costs a considerable amount in both staff time and technology to complete. While we are deeply committed to ensuring the highest quality care — which requires evaluating performance and acting on the findings — it is imperative that we direct our limited resources to the highest impact areas. Unfortunately, hospitals are subject to significant outdated reporting requirements, in particular with respect to the COVID-19 public health emergency. Eliminating this unnecessary reporting would reduce costs in the health care system and enable providers to spend more time with their patients. Our immediate recommendation is to eliminate the requirements for post-acute care providers to report COVID-19 vaccine rates for patients/residents and staff (86 FR 42489, 86 FR 45446, 86 FR 42396, 88 FR 51009, 88 FR 53233, 88 FR 59250, 88 FR 77767), for hospitals to report staff COVID-19 vaccination rates (86 FR 45382), and for hospitals and skilled nursing facilities to report data on acute respiratory illnesses, including influenza, COVID-19, and RSV, once per week, with more frequent and extensive data reporting required during a public health emergency (42 CFR 482.42(e), 42 CFR 483.90(g), 42 CFR 485.426(e) and 42 CFR 485.640(d)).</p><p><strong>Replace the sepsis bundle measure, as required at 79 FR 50241 and 88 FR 59801, with a measure of sepsis outcomes.</strong> Hospitals have spent considerable effort — and achieved significant results — in mitigating the incidence and severity of sepsis, saving lives in the process. Unfortunately, research has demonstrated that the sepsis bundle measure has not led to better outcomes yet entails an enormous administrative burden. We encourage the administration to work with hospitals on a measure that will help them further advance the fight against sepsis, while reducing unnecessary burdens in the system.</p><p><strong>Eliminate duplicative “look back” validation surveys of accrediting organizations (AOs) at 42 CFR 488.9 and permanently adopt concurrent validation surveys.</strong> As part of its oversight process, CMS conducts a full re-survey of hospital compliance with Medicare Conditions of Participation on a representative sample of hospitals each year, comparing each hospital’s results with the most recent accreditation surveys. Instead of fulfilling CMS’ goal of assessing AO performance, the validation surveys result in rework and disruption for hospitals and health systems. CMS should instead permanently adopt concurrent validation surveys that would allow the agency to directly observe AO performance.</p><p><strong>Resume conducting low-risk complaint surveys virtually.</strong> During the COVID-19 pandemic, CMS adopted a policy in which accrediting organizations and state survey agencies could conduct complaint surveys of low-risk quality issues virtually. Since then, CMS has instructed AOs to conduct most complaint surveys in person, regardless of severity, and hospitals incur costs for each AO visit. Virtual surveys for low-risk complaints would enable more efficient use of survey resources and reduce administrative costs.</p><p><strong>Facilitate whole-person care by eliminating 42 CFR Part 2 requirements that hinder care team access to important health information and protect patient privacy under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).</strong> Despite regulatory changes in the past several years, the regulations in Part 2 are outdated, fail to protect patient privacy and erect sometimes insurmountable barriers to providing coordinated, whole-person care to people with a history of substance use disorder (SUD). Specifically, the regulations require the separation of records pertaining to SUD information, which prevents the integration of behavioral and physical health care because the patient data cannot be used and disclosed like all other health care data.</p><h2>TELEHEALTH</h2><p>As technology and consumer preferences have evolved, more care can safely be delivered via telehealth. However, numerous regulations restrict the use of virtual care, impeding innovation and our ability to deliver care more efficiently. While there are numerous ways to expand access to care using telehealth, we recommend starting with the following.</p><p><strong>Remove telehealth originating site restrictions within the Medicare program at Sec. 1834(m)(4)(C)(ii)(X) of the Social Security Act (42 U.S.C. 1395m) and 42 CFR 410.78(b)(3) to enable patients to receive telehealth in their homes.</strong> Under current rules, patients must be in a clinical site of care, which completely undermines the value of telehealth for patients, limits its adoption and adds costs for providers.</p><p><strong>Remove telehealth geographic site restrictions within the Medicare program at Sec. 1834(m)(4)(C)(i) of the Social Security Act (42 U.S.C. 1395m) and 42 CFR 410.78(b)(4) to enable beneficiaries in non-rural areas to have the same access to virtual care as those in rural areas.</strong></p><p><strong>Remove the in-person visit requirements for behavioral health telehealth at Sec. 1834(m)(7) of the Social Security Act (42 U.S.C. 1395m) and 42 CFR 410.78(b)(3)(xiv), which is unnecessary, adds a barrier to access and creates a disparity between physical and mental health services.</strong></p><p><strong>Remove requirements at Sec. 3132 of the Affordable Care Act (42 U.S.C. 18001 et. seq.) and 42 CFR 418.22(4) that require hospice recertification to be completed in person to allow for hospice recertification to be completed via telehealth.</strong> This change would alleviate the burden on patients and their caregivers, as well as on clinicians.</p><h2>WORKFORCE</h2><p>The health care system’s greatest asset is our workforce. Unfortunately, doctors, nurses, technicians and others are increasingly burned out and leaving the profession, often citing excessive administrative burden that pulls them away from patient care. We recommend the following.</p><p><strong>Streamline care plan documentation requirements at 42 CFR 483.23(b)(4). </strong>To provide higher quality, more holistic care, patients are increasingly cared for by interdisciplinary teams. These teams may include a range of clinical professionals, such as nurses, therapists, and social workers. When used, these teams develop what is known as an interdisciplinary care plan. Yet, outdated regulations require nursing-specific care plans. Hence, as more care moves to interdisciplinary teams, clinicians must create duplicate paperwork to document the care plan.</p><p><strong>Eliminate the telehealth physician home address reporting requirement, which is currently under waiver as referenced at 89 FR 97110. </strong>Without continued waivers or removal, telehealth providers must list their home address on publicly available enrollment and claims forms when performing telehealth services from their homes, compromising their privacy and safety.</p><p><strong>Eliminate nurse practitioner and other advanced practice practitioner (APP) limitations at 42 CFR 485.604(a)(2), 42 CFR 485.604(b)(1)-(3), and 42 CFR 485.604(c)(1)-(3).</strong> These regulations impose limits on the scope of care APPs may provide that are often more restrictive than under state licensure, despite states having primary responsibility for clinical scope of practice rules. In these cases, hospitals and health systems are constrained in their ability to increase patient access to care through the greater use of APPs.</p><p><strong>Remove requirements at 42 CFR 410.61 that require outpatient physical therapy plans of care to be signed off by a physician or non-physician practitioner every 90 days. </strong>While CMS made an exception to the treatment plan signature requirement in the calendar year 2025 Physician Fee Schedule for initial care plans where there is a signed referral, the requirement for physicians to sign and date plans of care every 90 days creates an additional administrative burden.</p><p>Our attached recommendations also identify ways in which the administration can help reduce burdens caused by private sector stakeholders. While significant consolidation in the insurance industry exists, each insurer can offer thousands of unique health plan configurations, each often with its own rules and processes, such as which services are covered and the clinical criteria used to determine coverage. While we support the innovation and choice that these private entities bring to the health care system, this level of variation creates a tremendous amount of burden on providers. Fortunately, there are actions the administration can take to ease the cost and burden on providers of working with these payers, including addressing insurer consolidation that has given these companies the ability to unilaterally impose considerable burdens on providers.</p><p>Thank you for your consideration. We look forward to working with the administration on the much-needed effort to reduce regulatory red tape so that America’s hospitals and health systems can best support the health of their communities.<strong> </strong>Please contact me if you have questions, or feel free to have a member of your team contact Ashley Thompson, AHA’s senior vice president for policy analysis and development, at (202) 626-2688 or <a href="mailto:athompson@aha.org">athompson@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Rick Pollack<br>President and CEO</p><p><strong>Attachment: 100 Ways to Free Hospitals from Wasteful and Burdensome Administrative Requirements to Provide the Highest Quality, Most Efficient Care to Patients </strong></p><p>View the letter and attachment below.</p><div><p>__________</p><div id="ftn1"><div id="ftn1"><div id="ftn1"><p><small class="sm"><sup>1</sup> “Active steps to reduce administrative spending associated with financial transactions in US health care,” Sahni, N., et. al., Health Affairs Scholar, Volume 1, Issue 5, November 2023, qxad053, </small><a class="ck-anchor" href="https://doi.org/10.1093/haschl/qxad053" id="https://doi.org/10.1093/haschl/qxad053"><small class="sm">https://doi.org/10.1093/haschl/qxad053</small></a><br><small class="sm"><sup>2</sup> “The volume and cost of quality metric reporting,” Sarawasthula A et al. Journal of the American Medical Association. Volume 329, Number 21. June 6, 2023. 1840-1847.</small><br><small class="sm"><sup>3</sup> “Observations from the field: Reporting Quality Metrics in Health Care.” Dunlap NE et al. National Academies Press; 2016. </small><a class="ck-anchor" href="https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf" id="https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf"><small class="sm">https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf</small></a><br><small class="sm"><sup>4 </sup>“US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures.” Casalino LM et al. Health Affairs. Volume 35, Number 3. March 2016</small><br><small class="sm"><sup>5</sup>  </small><a class="ck-anchor" href="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/" id="https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/"><small class="sm">https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/</small></a><br><small class="sm"><sup>6</sup> </small><a class="ck-anchor" href="https://premierinc.com/newsroom/policy/80-premier-members-call-for-medicare-advantage-changes-to-address-payment-denials-and-delays" id="https://premierinc.com/newsroom/policy/80-premier-members-call-for-medicare-advantage-changes-to-address-payment-denials-and-delays"><small class="sm">https://premierinc.com/newsroom/policy/80-premier-members-call-for-medicare-advantage-changes-to-address-payment-denials-and-delays</small></a></p><p><small class="sm"><sup>7</sup> </small><a class="ck-anchor" href="https://www.kaufmanhall.com/insights/thoughts-ken-kaufman/implications-national-hospital-flash-report-hospital-operations" id="https://www.kaufmanhall.com/insights/thoughts-ken-kaufman/implications-national-hospital-flash-report-hospital-operations"><small class="sm">https://www.kaufmanhall.com/insights/thoughts-ken-kaufman/implications-national-hospital-flash-report-hospital-operations</small></a><br><small class="sm">8 </small><a class="ck-anchor" href="https://www.healthaffairs.org/content/forefront/administrative-spending-contributes-excess-us-health-spending" id="https://www.healthaffairs.org/content/forefront/administrative-spending-contributes-excess-us-health-spending"><small class="sm">https://www.healthaffairs.org/content/forefront/administrative-spending-contributes-excess-us-health-spending</small></a><br><small class="sm"><sup>9 </sup> “The volume and cost of quality metric reporting,” Sarawasthula A et al. Journal of the American Medical Association. Volume 329, Number 21. June 6, 2023. 1840-1847.</small><br><small class="sm"><sup>10</sup> “Observations from the field: Reporting Quality Metrics in Health Care.” Dunlap  NE et al. National Academies Press; 2016. </small><a class="ck-anchor" href="https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf" id="https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf"><small class="sm">https://nam.edu/wp-content/uploads/2016/07/Observations-from-the-Field-Reporting-Quality-Metrics-in-Health-Care.pdf</small></a><br><small class="sm"><sup>11</sup> “US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures.” Casalino LM et al. Health Affairs. Volume 35, Number 3. March 20</small>16. </p><hr><p class="text-align-center">Attachment<br><br><strong>100 Ways to Free Hospitals from Wasteful and Burdensome Administrative Requirements to Provide the Highest Quality, Most Efficient Care to Patients </strong></p><h2>BILLING, PAYMENT AND OTHER ADMINISTRATIVE REQUIREMENTS </h2><p>Research estimates that between 25% and 35% of all health care spending is on administrative tasks, with billing and collections, which include coverage and eligibility verification, being one of the costliest areas. The following changes could dramatically lower administrative costs; many would also improve patient access to care. </p><h3>Interactions with Health Plans</h3><ol><li>Eliminate duplicative and costly billing infrastructure within hospitals, health systems and other providers by shifting cost-sharing collection responsibilities to insurers — the entities that set co-pay, deductible and co-insurance amounts.</li><li>Reduce variation in prior authorization processes by enforcing the interoperability and prior authorization final rule, which will streamline electronic prior authorization processes across many payers.</li><li>Eliminate billions in excess health care system costs, resulting from providers chasing payment from insurers, by establishing prompt pay requirements in all forms of health care coverage, including Medicare Advantage.</li><li>Implement a standardized claims attachment to allow plans to request and providers to transmit necessary medical records via a safe electronic transmission standard.</li><li>Reduce the time providers waste tracking down the unique criteria that each Medicare Advantage plan uses to adjudicate claims by establishing a single clinical standard for both Traditional Medicare and Medicare Advantage.</li><li>Reduce the time patients spend waiting for post-acute care placements by disallowing plans from implementing prior authorization requirements for these services in certain circumstances.</li><li>Eliminate duplication and data collection burdens on providers by establishing a single national provider directory and requiring plans to exclusively use the national database rather than create their own.</li><li>Remove requirements for payers and plans to have separate credentialing processes and allow for payers to instead recognize hospital credentialing.</li><li>Adopt a standard process for providers to appeal a Medicare Advantage plan denial of a prior authorization request or claim.</li><li>Minimize the burden of managing pharmaceutical supplies while improving patient safety by prohibiting insurers from unilaterally adopting policies that force providers to use pharmaceuticals provided by the insurer’s affiliated pharmacy benefit manager rather than using their own supply (also known as “white bagging”).</li><li>Establish and enforce network adequacy requirements for post-acute care on Medicare Advantage plans to enable patients to begin necessary post-acute care as timely as possible while freeing up inpatient capacity.</li><li>Improve the flawed and cumbersome No Surprises Act Independent Dispute Resolution process while retaining the patient protections against surprise billing to allow insurers and out-of-network hospitals and health systems to work together more efficiently to determine appropriate reimbursement.</li><li>Remove the prior authorization requirement for non-emergent Veterans Affairs community care network services, which requires providers to submit a form that takes at least three days to process, therefore unnecessarily delaying care.</li><li>Expand access to alternative coverage options for employees, such as through Individual Reimbursement Arrangements, which would reduce the administrative burden on employers.</li></ol><h3>Information Technology and Coding</h3><ol start="15"><li>Repeal the excessive and confusing “information blocking” rule that would impose unjustified penalties on providers.</li><li>Modify the HIPAA cybersecurity rule of December 2024 to make the requirements voluntary.</li><li>Modify the HIPAA Breach Notification Rule to remove the requirement to report breaches affecting fewer than 500 individuals.</li><li>Eliminate billing and coding requirements for psychiatric care at 42 CFR 483.102as they are overly stringent and not based on medical criteria.</li><li>Streamline the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) code sets to standardize reporting across all payors.</li><li>Eliminate unique HCPCS codes for generic drugs, which adds burden by complicating the billing process. </li></ol><h3>Administrative and Regulatory Barriers to Care</h3><ol start="21"><li>Repeal the Food and Drug Administration Laboratory Developed Tests final rule that will hamper hospital labs’ ability to continue developing high-quality in-vitro tests that have increased access to care and reduced costs.</li><li>Repeal the Institutions for Mental Disease exclusion within the Medicaid program so that hospitals and other providers can ensure Medicaid patients who need inpatient behavioral health care can get the most effective care efficiently.</li><li>Similarly, repeal the 180-day lifetime limit on inpatient psychiatric facility services under Medicare.</li><li>Allow inpatient rehabilitation facilities (IRFs) to care for more than just inpatient rehabilitation patients when capacity is an issue (such as during a pandemic), which could reduce patient wait times for care.</li><li>Eliminate the observation hours “carve-out” policy for diagnostic or therapeutic services.</li><li>Simplify the detailed and complex reporting process of the Medicare Cost Reports.</li><li>Modernize the Stark Law and Anti-kickback Statute regulations to better protect arrangements that promote value-based care.</li><li>Repeal the requirement that Critical Access Hospital (CAH) based ambulance services only receive cost-based reimbursement if they are the sole ambulance provider within 35 miles. Instead, all CAH-based ambulance providers should receive cost-based reimbursement.</li><li>Modify Environmental Protection Agency project building timelines that significantly delay the construction of new sites of care.</li><li>Expand hospitals’ ability to utilize swing beds.</li><li>Improve the timeliness and efficiency of 340B child site registration by re-adopting the prior policy of allowing hospitals to register child sites under the 340B program even if they are not included on their most recently filed cost report.</li></ol><h3>Medicare Payment and Processes</h3><ol start="32"><li>Repeal the IRF Review Choice Demonstration under which IRFs will have 100% of their traditional Medicare claims subject to either pre- or post-claim review for at least six months.</li><li>Repeal the Center for Medicare and Medicaid Innovation’s (CMMI) Increasing Organ Transplant Access mandatory kidney transplant model that purports to better align payment with quality but over-focuses on quantity over quality.</li><li>Make voluntary all CMMI models with particular focus on the recently announced Transforming Episode Accountability Model, which will mandate that some of the most vulnerable hospitals transition to bundled payments for five types of surgical episodes.</li><li>Eliminate the skilled nursing facility three-day length of stay requirement that often delays patients from transitioning to the most appropriate site of care.</li><li>Simplify and expedite discharge processes by removing the requirement that hospitals provide patients with a list of post-acute care (PAC) providers from which to select when hospitals already work with patients and PAC providers for appropriate placement.</li><li>Eliminate the CAH 96-hour rule as a condition of participation (CoP) which requires an annual average length of stay of 96 hours or less and eliminate the 96-hour condition of payment rule that requires physicians in CAHs to certify upon admission that an inpatient can be reasonably expected to be discharged or transferred to another hospital within 96-hours.</li><li>Eliminate the requirement that a hospital operate for at least six months under the prospective payment system before converting to CAH status.</li><li>Eliminate the “must-bill” policy for dual eligible beneficiaries, which requires providers to bill both Medicare and Medicaid even though no Medicaid payment may be expected.</li><li>Allow for exceptions to the requirement that Medicare overpayments are returned in 180 days, given that providers may need additional time to complete investigations.</li><li>Allow Medicare bad debts to be written off as contractual allowances, which is consistent with standard accounting practices and was permitted under prior policies.</li><li>Eliminate the policy that to receive Medicare bad debt reimbursement for dual eligible beneficiaries, providers must bill the state Medicaid program AND receive/submit the remittance advice listing any Medicaid payment, which is burdensome and not always possible.</li><li>Standardize coverage, coding and billing criteria among Medicare Administrative Contractors (MACs).</li><li>Remove the restriction that disallows hospitals from choosing a different MAC.</li><li>Streamline the Medicare appeals process to allow uploading of medical records at the time of claim filing.</li><li>Streamline Medicare mandatory notices to patients, including eliminating where applicable rules require providers to give notice both in-person and via paper notices. Examples of such notices include the Important Message from Medicare, Advance Beneficiary Notice of Non-coverage, and Medicare Outpatient Observation Notice, the Notice of Medicare Non-Coverage and Medicare Change of Status Notice.</li><li>Rescind Centers for Medicare and Medicaid Services (CMS) regulations requiring hospitals to report detailed information about drug invoices on their cost reports beginning in 2026. Manufacturers should be required to report the additional pricing information necessary for CMS to create average sales prices.</li><li>Revise Medicare drug price negotiation guidance to prohibit drug manufacturers from implementing retrospective rebate models in the 340B Drug Pricing Program, which would add considerable administrative costs to hospitals serving the most vulnerable communities.</li><li>Strengthen Medicare-dependent and Sole Community Hospitals by allowing participating hospitals to choose from an additional base year when calculating payments. </li></ol><h3>Price Transparency </h3><ol start="50"><li>Eliminate the convening provider requirement as part of good faith price estimates given to patients, because there is no technical solution to operationalize it.</li><li>Create a more streamlined and accurate process for patients to access pricing information by having insurers serve as the “source of truth” by publishing the negotiated rates and requiring hospitals to post cash price and chargemaster rates. </li></ol><h2>QUALITY AND PATIENT SAFETY </h2><p>High-quality, safe care is the core of hospitals’ missions. While many regulations originated out of an interest to improve care quality or patient safety, those same regulations, over time, have often become obsolete or redundant. However, in many cases, they remain required despite having outlived their usefulness. The following changes would support hospitals’ efforts to adapt to continue offering the highest quality, safest care. </p><h3>Quality Reporting </h3><ol start="52"><li>Repeal the onerous and now outdated CoP that requires hospitals to report data on acute respiratory illnesses, including influenza, COVID-19 and RSV, once per week, with more frequent and extensive data reporting required during a public health emergency.</li><li>Reduce administrative burden by eliminating the outdated requirement for post-acute care providers to report COVID-19 and influenza vaccine rates for patients/residents and staff.</li><li>Similarly, remove the outdated requirement for hospitals to report staff vaccination rates.</li><li>Remove the sepsis bundle measure, which evidence shows has not led to better outcomes but entails an enormous administrative burden, from all hospital quality reporting and value programs, replacing it with a measure of sepsis outcomes.</li><li>Eliminate (or at minimum streamline) the Meaningful Use (now Promoting Interoperability) program as it has outlived its usefulness.</li><li>Eliminate (or, at a minimum, significantly streamline) the onerous Hospital Consumer Assessment of Healthcare Providers and Systems (patient satisfaction) survey of hospitals, as the quality of the instrument and use of the results have degraded due to low response rates.</li><li>Support quality and patient safety while reducing burdens by reducing the required reporting of electronic clinical quality measures to a more targeted set of core measures.</li><li>Remove the requirement for hospitals to report reflecting screening for social determinants of health measures that are not linked to better outcomes.</li><li>Eliminate the mandatory requirement for Accountable Care Organizations to report quality data electronically, versus allowing reporting via a web interface.</li><li>Eliminate the Hospital Readmission Reduction Program, as performance has topped out.</li><li>Suspend the Medicare hospital star ratings program as the methodology is inadequate, including distorted comparisons of hospital performance and a significant time lag.</li><li>Remove quality measures from the inpatient psychiatric quality reporting program that are not directly relevant to inpatient psychiatric care, such as whether the facility offers smoking cessation services.</li><li>Remove all structural measures from hospital quality reporting programs that have little evidence tying their use to better care or outcomes, including the Patient Safety Structural Measure, Health Equity Structural Measure and Age-Friendly Hospital measure.</li><li>Remove (or, at a minimum, make voluntary) the reporting of hybrid hospital readmissions/mortality measures and hip/knee arthroplasty patient-reported outcome measures due to significant feasibility issues.</li></ol><h3>Surveys and Accreditation</h3><ol start="66"><li>Minimize in-person hospital surveys for low-risk complaints and resume them virtually.</li><li>Permanently adopt concurrent validation surveys for CMS accrediting organizations, eliminating duplicative “lookback” surveys that require a full resurvey of hospital compliance with CoPs.</li><li>Allow hospitals time to ensure adequate staffing and resources during surveys without compromising the integrity of those surveys by eliminating the prohibition on accrediting organizations providing same-day notification of a survey.</li><li>Eliminate punitive removals of “deemed status” when a hospital has one or more condition-level citations on a validation survey, which is unnecessary for adequate oversight. </li></ol><h3>Other</h3><ol start="70"><li>Repeal the nursing home staffing rule that would not improve quality or safety and would require nearly 80% of all nursing homes — including those with five stars — to increase staffing.</li><li>Revise the obstetrical care CoP by removing requirements that are not directly relevant to improving obstetrical care and redundant with existing requirements, such as requirements focused on non-obstetrical emergencies, supplies and training.</li><li>Reduce unnecessary burden while ensuring adequate emergency response preparation by reducing the number of required hospital emergency preparedness drills to once a year.</li><li>Remove the requirement that hospitals provide translation services for patients in 15 different languages and instead allow hospitals to ensure adequate translation for the populations they serve.</li><li>Enable inpatient psychiatric facilities (IPFs) to provide appropriate monitoring of patients at risk of suicide without overburdening the workforce or adding unnecessary costs by eliminating the requirement that IPFs have one-to-one monitoring of patients at risk of suicide.</li><li>Eliminate 42 CFR Part 2 requirements providing special privacy protections for behavioral health patients and protect their privacy under HIPAA.</li><li>Eliminate the Occupational Safety and Health Administration (OSHA) “walkaround rule” that allows union representatives to accompany OSHA inspectors.</li><li>Enable hospitals to reduce costs by limiting the requirement to purchase supplies through CMS-approved vendors to only medical devices and other aspects of direct patient care and exempting non-clinical items such as office furniture and supplies.</li><li>Support providers’ access to cheaper drugs by enforcing rules to prevent gaming of patents and other policies that stifle pharmaceutical competition. </li></ol><h2>TELEHEALTH </h2><p>As technology and consumer preferences have evolved, more care can safely be delivered via telehealth. However, numerous regulations restrict the use of virtual care. Addressing the following areas would not only reduce unnecessary burdens on the health care system but also improve clinician capacity, increasing access to care. </p><ol start="79"><li>Remove telehealth originating site restrictions to enable patients to receive telehealth in their homes.</li><li>Remove telehealth geographic site restrictions to enable beneficiaries in non-rural areas to have the same access to virtual care as those in rural areas.</li><li>Remove restrictions on telehealth modalities to enable a wider range of services (e.g., audio only) to be safely delivered via telehealth.</li><li>Similarly, remove restrictions on the provider types eligible to perform telehealth.</li><li>Remove restrictions on the types of distant sites eligible to perform telehealth services.</li><li>Allow hospital outpatient departments to bill for telehealth services when patients are in their homes (assuming statutes are updated to allow for telehealth to patients' homes permanently).</li><li>Remove the in-person visit requirements for behavioral health telehealth.</li><li>Remove restrictions to allow new patients to receive remote physiologic monitoring.</li><li>Remove case-by-case approval of new telehealth services; instead, include all Medicare-covered services as eligible telehealth services and remove them on a case-by-case basis.</li><li>Remove in-person visit requirements prior to prescribing controlled substances by establishing a special registration process for virtual prescribers.</li><li>Remove requirements for hospice recertification to be completed in person to allow for telehealth-based recertification.</li></ol><h2>WORKFORCE</h2><p>The health care system’s greatest asset is our workforce. Unfortunately, doctors, nurses, technicians and others are increasingly burned out and leaving the profession, often citing excessive administrative burden that pulls them away from patient care. The following regulatory relief ideas would support our workforce.</p><ol start="90"><li>Eliminate the telehealth physician home address reporting requirement, which compromises workforce safety.</li><li>Remove requirements for outpatient physical therapy plans of care to be signed off by a physician or nurse practitioner every 90 days.</li><li>Reform nursing and allied health education payments to relax the CMS interpretation of "director control.”</li><li>Eliminate or raise the tax-free limit of $5,250 on employer-provided funds spent to train employees in high-demand services like radiology.</li><li>Repeal the Federal Trade Commission's Non-Compete Clause Rule.</li><li>Reform rules related to “fair market value” to ensure that hospitals can obtain access to necessary specialist services.</li><li>Eliminate nurse practitioner practice limitations that are more restrictive under CMS rules than under state licensure.</li><li>Promote medical licensure reciprocity to allow practitioners to work across state lines.</li><li>Do not promulgate Occupational Safety and Health Administration federal workplace violence regulations that would be duplicative of the rigorous accreditation requirements hospitals already face and add an administrative burden.</li><li>Reduce unnecessary costs in the system by pursuing medical liability reform by eliminating joint and several liability.</li><li>Similarly, cap non-economic and punitive damages as part of medical liability. </li></ol></div></div></div></div> Mon, 12 May 2025 11:39:47 -0500 Billing & Collections /news/headline/2025-01-07-cfpb-finalizes-rule-banning-inclusion-medical-debt-credit-reports <div><p lang="EN-US" lang="EN-US" paraid="1959663768" paraeid="{f5f6db5d-7dd7-49ca-8279-b67cbf71fbc9}{16}">The Consumer Financial Protection Bureau today <a href="https://www.consumerfinance.gov/about-us/newsroom/cfpb-finalizes-rule-to-remove-medical-bills-from-credit-reports/" target="_blank">released a final rule</a> Jan. 7 banning medical bills on credit reports and prohibiting lenders from using medical information in lending decisions. The rule will remove an estimated $49 billion in medical bills from credit reports for nearly 15 million Americans. The CFPB said Americans with medical debt on their credit reports could see their credit scores increase by an average of 20 points.  </p></div><div><p lang="EN-US" lang="EN-US" paraid="738692707" paraeid="{addc9a36-60d3-495c-bb41-1420c477f18c}{235}">The final rule will become effective 60 days after publication in the Federal Register.</p></div> Tue, 07 Jan 2025 14:30:38 -0600 Billing & Collections /aha-center-health-innovation-market-scan/2024-10-15-4-health-systems-team-tackle-drug-development-care-coordination-and-billing <div class="container"><div class="row"><div class="col-md-8"><img src="/sites/default/files/inline-images/4-Health-Systems-Team-Up-to-Tackle-Drug-Development-Care-Coordination-and-Billing.png" data-entity-uuid="cc708067-d6ca-4b77-9008-533ef3e88f67" data-entity-type="file" alt="4 Health Systems Team Up to Tackle Drug Development, Care Coordination and Billing. A silver hand and a gold hand fist bump." width="100%" height="100%" class="align-center"><p>Addressing weighty issues that confront health care, such as increasing access to complex drugs, care coordination within huge programs like Medicare Advantage and streamlining billing processes, is tough for any organization trying to go it alone. So maybe it’s not surprising that four prominent nonprofit health systems — Baylor, Scott & White Health, Memorial Hermann Health System, Novant Health and Providence — have banded together to form a for-profit entity to tackle these challenges.</p><p>The new organization, <a href="https://www.providence.org/news/uf/689043632?streamid=4347370%5C" target="_blank" title="Providence: Leading Health Systems Form New Organization to Transform the Development and Delivery of Health Care Solutions">Longitude Health</a>, will draw on the expertise of founding member organizations while it tries to recruit more health systems and investors over the next 12 months.</p><p>Initially, Longitude Health plans to form three operating startup companies that will focus on pharmaceutical development, improving care coordination and streamlining billing practices. The organization hopes to create additional operating companies in the coming years. Paul Mango, former chief of staff at the Centers for Medicare & Medicaid Services, will be CEO of the new venture, with CEOs from the four health systems comprising the Longitude board.</p><p>“Health systems must transcend traditional care delivery strategies and embrace innovative business models that serve the broader health care community,” said Rod Hochman, M.D., president and CEO of Providence. “To do so, it is imperative that we work with other like-minded partners facing similar challenges to build up new capabilities. By implementing solutions that benefit multiple health systems, we can drive down costs and ensure the sustainability of health care delivery. We will lead the charge in shaping a brighter future for health care delivery.”</p><p>Health system-led ventures like the generic drug company CivicaRx and the data analytics firm Truveta are models that Longitude can build on, Hochman told <a href="https://www.modernhealthcare.com/providers/longitude-health-providence-baylor-scott-white-novant-memorial-hermann" target="_blank" title="Modern Healthcare: 4 nonprofit health systems launch Longitude Health">Modern Healthcare in a recent interview</a>. If Longitude can develop solutions that demonstrate value, the organization will share those with the field, he said.</p><p><span><strong>Initial aims of the Longitude startup companies include:</strong></span></p><ul><li><strong>Improving access to drugs</strong> like monoclonal antibodies used to treat cancer and infectious diseases.</li><li>Working closely with physicians to <strong>limit readmissions</strong>, at the request of Medicare Advantage plans. The company will help health systems refine treatment and improve care transitions.</li><li>Consolidating medical bills into a <strong>single invoice</strong> that shows what a patient owes.</li></ul><p>In January, Longitude plans to hold a competition among the four health system members to determine what Longitude’s next focus should be, which could be related to health information technology, cybersecurity, labor productivity or value-based care.</p></div><div class="col-md-4"><p><a href="/center" title="Visit the AHA Center for Health Innovation landing page."><img src="/sites/default/files/inline-images/logo-aha-innovation-center-color-sm.jpg" data-entity-uuid="7ade6b12-de98-4d0b-965f-a7c99d9463c5" alt="AHA Center for Health Innovation logo" width="721" height="130" data-entity- type="file" class="align-center"></a></p><p><a href="/center/form/innovation-subscription"><img src="/sites/default/files/2019-04/Market_Scan_Call_Out_360x300.png" data-entity-uuid data-entity-type alt width="360" height="300"></a></p></div></div></div>.field_featured_image { position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } .featured-image{ position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } Tue, 15 Oct 2024 06:00:00 -0500 Billing & Collections /special-bulletin/2024-09-25-cms-issues-aco-significant-anomalous-and-highly-suspect-billing-final-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Sept. 24 issued a <a href="https://public-inspection.federalregister.gov/2024-22054.pdf">final rule</a> that would carve out significant, anomalous and highly suspect (SAHS) billing from Medicare Shared Savings Program (MSSP) financial calculations for calendar year (CY) 2023. This final rule is part of a larger strategy to address SAHS billing activity within accountable care organizations (ACOs) reconciliation. Specifically, the agency also addressed this issue for CY 2024 and beyond in the CY 2025 physician fee schedule proposed rule, on which the AHA <a href="/lettercomment/2024-09-09-aha-comments-cms-physician-fee-schedule-cy-2025-proposed-rule" target="_blank">commented</a>. This rule’s changes are effective Oct. 15.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The rule:</p><ul><li>Finalizes two urinary catheter codes involved in SAHS billing activity for CY 2023.</li><li>Adjusts ACOs’ performance year and benchmark year calculations for CY 2023 to account for this activity, including when CY 2023 is the performance year and when it is used to establish benchmarks for 2024, 2025 and 2026.</li><li>Excludes CY 2023 amounts from factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025.</li></ul></div></div><h2>AHA Take</h2><p>The AHA applauds CMS for recognizing the significant impact that anomalous catheter spending would have on ACO participants and for taking action to carve out these expenditures from ACO financial calculations. Indeed, the recent catheter billing issue increased some ACOs’ total spending by as much as 2%. As such, in many cases, the inclusion of this spending would have led to a loss of shared savings. We are pleased that the agency listened to the <a href="/lettercomment/2024-04-30-letter-cms-administrator-brooks-lasure-higher-spending-two-catheter-codes-and-impact-acos" target="_blank" title="Recommendations from AHA and Others">recommendations</a> from AHA and others to hold ACOs harmless for such spending beyond their control.</p><p>While this is a significant step to mitigate the impact of anomalous spending for CY 2023, the 2023 catheter spending is not the first, and unfortunately likely not the last, instance of suspected fraudulent billing. We are encouraged that this is part of a broader strategy to mitigate anomalous spending and will continue to work with the agency to develop future policies to address this issue. </p><p>Highlights of the SAHS final rule follow.</p><h2>Identifying Codes Displaying SAHS Billing Activity in CY 2023</h2><p>The agency finalized that a health care common procedure coding system (HCPCS) or current procedural terminology (CPT) code exhibits SAHS billing activity when there is a significant increase in claims, either in volume or dollars, with national or regional impact, that represents a deviation from historical utilization trends that is unexpected and is not clearly attributable to reasonably explained changes in policy or the supply or demand for covered items or services. CMS determined that two HCPCS codes displayed SAHS billing activity in CY 2023: </p><ul><li>A4352 (Intermittent Urinary Catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.) each)</li><li>A4353 (Intermittent Urinary Catheter with insertion supplies)</li></ul><p>Both HCPCS codes were billed at significantly higher rates in CY 2023 compared to 2022 (an increase of 163% for A4352 and over 5,000% for A4353), but CMS could not determine a clear justification for these increases. The agency also analyzed HCPCS code A4351 but determined that it did not constitute SAHS billing activity, as it increased only 16% from CY 2022 to CY 2023. Additionally, the agency reviewed skin substitute codes and determined billing activity increases were explained by deviations in local coverage determinations across Medicare Administrative Contractors.</p><h2>Removing Payment Amounts from Financial Calculations</h2><p>CMS will exclude all Medicare Parts A and B payment amounts for selected catheter HCPCS codes from expenditure and revenue calculations for CY 2023. This includes when CY 2023 is the performance year and CY 2023 is a benchmark year for ACOs in agreement periods beginning on Jan. 1, 2024, Jan. 1, 2025, and Jan. 1, 2026. Amounts also will be excluded from calculating factors used in the application cycle for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025.</p><p>After receiving comments, the agency considered whether amounts also should be removed for CY 2022 and CY 2024. For performance years prior to CY 2023, the agency determined that financial reconciliation already has been completed, and therefore, the policies applied in the SAHS billing rule would not address retrospective billing increases. For CY 2024 and beyond, the agency proposed changes in the CY 2025 physician fee schedule that should be finalized around Nov. 1.</p><p>CMS also received comments requesting the application of guardrails for organizations that may, for example, have shared savings decremented by removing SAHS catheter billing. The agency determined that it would not apply guardrails for adjustments to financial calculations.</p><p>Finally, the agency considered comments regarding making similar adjustments for catheter codes in other programs like the ACO Realizing Equity, Access, and Community Health (ACO REACH), Bundled Payments for Care Improvement  Advanced, and Comprehensive Care for Joint Replacement models. However, it determined that this would be beyond the scope of this rule. CMS states that the Center for Medicare and Medicaid Innovation assessed the effects of SAHS billing on each model and made determinations of whether actions were necessary on a model-by-model basis.</p><h2>Further Questions</h2><p>If you have further questions regarding the SAHS billing final rule, please contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/09/cms-issues-aco-significant-anomalous-and-highly-suspect-billing-final-rule-bulletin-9-25-2024-f.pdf"><img src="/sites/default/files/inline-images/cover-cms-issues-aco-significant-anomalous-and-highly-suspect-billing-final-rule-bulletin-9-25-2024-f-2.pdf_.png" data-entity-uuid data-entity-type="file" width="640" height="834"></a></div></div></div> Wed, 25 Sep 2024 15:33:26 -0500 Billing & Collections /news/headline/2024-07-29-aha-comments-cms-proposed-rule-mitigate-impact-fraudulent-catheter-billing <p>The AHA July 29 applauded a proposed rule by the Centers for Medicare & Medicaid Services to address concerns raised by the AHA and other organizations about the potential impact of significant, anomalous and highly suspect catheter billing within the Medicare Shared Savings Program. CMS data showed a 20-fold increase in catheter billing from 10 durable medical equipment suppliers over two years, equivalent to a nearly $3 billion increase in spending. The AHA supported CMS' proposal to hold ACOs harmless for SAHS catheter billing that occurred in calendar year 2023, and specifically supported exclusion of catheter billing codes submitted by any supplier from MSSP expenditure and revenue calculations for CY 2023. "Inclusion of this anomalous billing in accountable care organization (ACO) spending figures for CY 2023 would have a severely inappropriate impact on these calculations," AHA <a href="/2024-07-29-comment-letter-cms-proposed-rule-mitigate-impact-significant-anomalous-and-highly-suspect-billing-activity-within">wrote</a> to CMS. "Indeed, the recent catheter billing issue increased some ACOs’ total spending by as much as 2%. As such, in many cases, inclusion of this spending would actually lead to a loss of shared savings." </p> Mon, 29 Jul 2024 14:02:23 -0500 Billing & Collections /2024-07-29-comment-letter-cms-proposed-rule-mitigate-impact-significant-anomalous-and-highly-suspect-billing-activity-within <div class="container"><div class="row"><div class="col-md-8"><p>July 29, 2024</p><p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p><p><em><strong>RE: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in CY 2023</strong></em></p><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers, and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed rule to mitigate the impact of significant, anomalous and highly suspect (SAHS) billing activity within the Medicare Shared Savings Program (MSSP) in calendar year (CY) 2023.</p><p><strong>We applaud CMS for taking quick action to develop proposals to address </strong><a href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf"><strong>concerns</strong></a><strong> raised by the AHA and other stakeholders regarding the potential impact of SAHS catheter billing.</strong> Specifically, data from the CMS Virtual Research Data Center showed a 20-fold increase in catheter billing on the part of 10 durable medical equipment (DME) suppliers over the course of two years, which was equivalent to an almost $3 billion increase in spending. Inclusion of this anomalous billing in accountable care organization (ACO) spending figures for CY 2023 would have a severely inappropriate impact on these calculations. Indeed, the recent catheter billing issue increased some ACOs’ total spending by as much as 2%. As such, in many cases, inclusion of this spending would actually lead to a loss of shared savings.</p><p><strong>We support CMS’ proposal to hold ACOs harmless for the SAHS catheter billing that occurred in CY 2023. Specifically, we support the exclusion from expenditure and revenue calculations of payment amounts for catheter billing codes submitted by any supplier.</strong> This would include when CY 2023 is the performance year, as well as when it is used for establishing benchmarks for 2024, 2025 and 2026. Additionally, we support that SAHS billing amounts would be excluded from factors used in the application for ACOs applying to enter a new agreement period beginning on Jan. 1, 2025. That said, while this proposed rule would apply only to the MSSP, we encourage the agency also to evaluate impact and pursue similar policies for other ACO programs outside of MSSP. For example, the ACO Realizing Equity, Access, and Community Health (REACH) model appears to have been similarly impacted by anomalous catheter billing.</p><p>We also encourage CMS to evaluate whether additional codes should be carved out of financial calculations for 2023. Some ACOs have reported, for example, that there have been similar increases in billing for skin substitutes (a $2.6 billion increase between 2022 and 2023) that also may artificially skew financial calculations and impact shared savings without action.</p><p>We recognize that even with a 30-day comment period, the process of carving out this spending from financial calculations may result in delays in timelines. Specifically, CMS stated that it anticipates a delay in reconciliation timelines by up to six weeks. <strong>Given the projected delays in reconciliation timelines, we encourage CMS to delay other ACO timelines, such as risk track selection deadlines and participation lists, to ensure alignment.</strong> Indeed, previous performance is an important factor that participants consider when determining whether, for example, they can assume more risk under a different performance track.</p><p>While this proposed rule marks a significant step to mitigate the impact of anomalous catheter spending for CY 2023, this is not the first, and unfortunately likely not the last, instance of ACOs reporting suspected fraudulent billing. <strong>As such, we commend CMS for including proposals to address the impact of SAHS in 2024 and future years as part of the CY 2025 physician fee schedule (PFS) proposed rule.</strong> We have <a href="/system/files/media/file/2024/04/Coalition-letter-on-Catheter-Spending-Impact-on-ACOs.pdf">urged</a> for long-term policies to support the identification of SAHS. For example, we have recommended the establishment of an outlier policy to detect variation in anomalous spending above a certain threshold and remove services from future calculations. There also are opportunities to improve how ACOs report fraud, as well as to better educate ACOs on the process CMS and the Health and Human Services (HHS) Office of Inspector General (OIG) undertake to investigate fraud. As the HHS OIG has previously noted, ACOs are excellent sources to uncover potential fraud, waste and abuse by identifying patterns of unusual billing. We will provide additional comments in response to the CY 2025 PFS proposed rule.</p><p>We appreciate CMS’ timely proposal on this issue and look forward to working collaboratively on developing a longer-term strategy to detect and address anomalous billing. Please contact me if you have questions or feel free to have a member of your team contact Jennifer Holloman, AHA’s senior associate director of policy, at <a href="mailto:jholloman@aha.org?subject=" comment letter proposed rule to mitigate the impact of anomalous and highly suspect billing activity within medicare shared savings program in cy>jholloman@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/07/Comment-Letter-on-CMS-Proposed-Rule-to-Mitigate-the-Impact-of-Significant-Anomalous-and-Highly-Suspect-Billing-Activity.pdf" target="_blank" title="Click here to download the Comment Letter on CMS’ Proposed Rule to Mitigate the Impact of Significant, Anomalous and Highly Suspect Billing Activity within the Medicare Shared Savings Program in CY 2023 PDF."><img src="/sites/default/files/inline-images/Page-1-Comment-Letter-on-CMS-Proposed-Rule-to-Mitigate-the-Impact-of-Significant-Anomalous-and-Highly-Suspect-Billing-Activity.png" data-entity-uuid="e6d08773-8155-4678-a0af-41705f88dd0d" data-entity-type="file" alt="Comment Letter on CMS’ Proposed Rule to Mitigate the Impact of Significant, Anomalous and Highly Suspect Billing Activity within the Medicare Shared Savings Program in CY 2023 page 1." width="692" height="900"></a></p></div></div></div> Mon, 29 Jul 2024 09:42:18 -0500 Billing & Collections /fact-sheets/2024-07-18-fact-sheet-hospital-outpatient-department-billing-requirements <div class="container row"><div class="row"><div class="col-md-8"><h2><span><em>The Issue</em></span></h2><p>The National Provider Identifier (NPI) is a unique identification number for covered health care providers (including physicians and hospitals) to help send information electronically more quickly and effectively. Congress is considering legislation that would change current billing practices for Medicare and the commercial insurance market to require each off-campus hospital outpatient department (HOPD) to be assigned a unique NPI as a condition of payment. However, these changes are unnecessary since hospitals already bill according to federal regulations, which require them to bill all payers — Medicare, Medicaid and private payers — using codes that indicate the location of where a service is provided.</p><h2><span><em>Background</em></span></h2><p>Under current law, when a patient is seen at an off-campus HOPD, the HOPD bills for the items and services rendered using the HIPAA-mandated institutional billing claim. The institutional claim requires that the hospital identify the type of bill (TOB) in each claim. Specifically, TOB 13X identifies that the bill is for a “hospital outpatient department.” Additionally, consistent with HIPAA and Medicare’s existing regulations, off-campus services must include the correct modifiers on the bill. Modifier “PO” must be appended to all items and services paid under the outpatient prospective payment system and rendered in an off-campus HOPD. Modifier “PN” must be appended to all items and services paid under the Medicare physician fee schedule and rendered in an off-campus outpatient department. Modifier “ER” must be appended for services in an off-campus emergency department. Moreover, the HIPAA-mandated institutional claim requires that the claim include the name and service location of the provider submitting the claim.<br>Current Medicare regulations require that beneficiaries who are treated at an off-campus HOPD receive notification of their expected financial obligations if they will be receiving bills from both the individual provider and the hospital.</p><h2><span><em>AHA Position</em></span></h2><p>The AHA is opposed to legislative efforts requiring each off-campus HOPD to be assigned a separate unique health identifier from its provider as a condition of payment under Medicare or group health plans. Hospitals are already transparent about the location of care delivery on their bills and this requirement would be duplicative and impose unnecessary and onerous administrative burdens and costs to needlessly overhaul current billing practices and systems.</p></div><div class="col-md-4"><img src="/sites/default/files/inline-images/cover-fact-sheet-hospital-outpatient-department-billing-requirements-850.png" data-entity-uuid="be271b2e-4af4-44d9-b78c-c0f921748c67" data-entity-type="file" width="NaN" height="NaN"></div><p> </p><div class="text-align-center"><p><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/07/fact-sheet-hospital-outpatient-department-billing-requirements.pdf" target="_blank" title="Click here to download the Fact Sheet: Hospital Outpatient Department Billing Requirements">Download the PDF</a></p><p> </p></div></div></div> Thu, 18 Jul 2024 15:23:27 -0500 Billing & Collections