Bluemark Article: Telehealth Expands and Audits Have Started
Do you have a technology solution in your strategy?

By: Lyman Sornberger, Principal with Lyman Healthcare Solutions and Bluemark Senior Strategic Advisor.

The COVID-19 pandemic has accelerated the use of telehealth and telemedicine across the U.S. healthcare landscape. Providers and patients should both benefit from this new trend, as remote services are helping to effectively provide care and deliver a revenue stop-gap during this time of patients concerns with engaging the healthcare system and practicing social distancing. The question is whether everyone is prepared for this new reality of patient care, particularly Patient Financial Service and Revenue Cycle Management? Secondarily, do providers have the resources, processes and partners in place to support this "new normal"?

Telehealth is largely providing revenue continuity and continuation of care with doctors minimizing cancelled patients visits, improving patient satisfaction, prescribing valuable medications, and maximizing potential healthcare revenue at a lower cost of service. Given some of the additional impacts of the pandemic it is anticipated that behavioral health and post care rehabilitation will soon jump on the telehealth band wagon.

All of this is good news for health systems and consumers, but it comes with one caveat, the demand for telehealth after the pandemic ends will depend on whether payers will continue to reimburse telehealth at the current levels. At the moment, its payout is higher than in the past due to temporary waivers that are slated to evaporate once the public health crisis ends.

Hospital executives typically say that telemedicine improves a patient's access to care. But truth be known it doesn't always come with a positive impact on either specifically Patient Financial Services or more broadly Revenue Cycle Management. In the short-term providers have interpreted the opportunity with telemedicine to be somewhat of a "green field". It has been assumed that many bills will be paid at levels of service that historically would not have been reimbursed. Some have interpreted the "relaxed rules" to be an opportunity to be compensated for additional services since elective services have declined. In other words, telehealth offers several opportunities to improve profitability and hospital revenue.

A recent KLAS survey, hospital executives noted that telehealth, at 49%, was their number one "innovation priority". Let's add that more than twenty years ago, patient responsibility was in the 5% range. Today it is more like 20% and many predict that it will reach as high as 30% in 2021. That represents a potentially significant loss that hospitals cannot afford to just write off. Given this larger share of responsibility, patients are more receptive to the "telehealth consumerism" concept with not only the convenience but also a savings to the historical visit costs. These costs can include: lost work wages, transportation, and the total time invested in an in-person care event. Some have even coined the term with telehealth as the new "concierge healthcare service".

Current data shows the value of a telehealth model in our current healthcare landscape. The Medical Group Management Association has documented that many hospitals have no show rates as high as more than 50%. Best run practices are now showing a 12% no show daily rate for visits. Historically, even 5% was painful to the provider's bottom line. Telehealth is showing a minimal no-show rate, immediate access to care, and patients are enthusiastic about not having to deal with the complexity of a real time visit. A recent MD Live survey found that adults 18 to 34 prefer same day health visits which are far more likely in a telehealth model of care. An Intel study found that more than 70% of patients are more receptive to telehealth care, regardless of age. It truly is all about consumerism of healthcare

As they say, "no good deed goes unpunished" and that has been true in healthcare revenue cycle for years. In spite of the recent flexibility to providers for reimbursing telehealth, providers are now facing the inevitable process of denials and audits. There is certainly some risk for providers, primarily due to their interpretation of the reasonable flexibility resulting from COVID-19. Additionally, CMS released the 2021 physician fee schedule on December 1st which included expanded telehealth services. Telehealth is growing and there are constant changes that will make these services a prime target for audits.

Recent audits are finding that PHI has been relaxed with telehealth, however that never meant that "over-coding" was not at risk. Recent examples in large health systems in OH, PA, AZ, FL, NC, and CA are finding that providers assumed the new COVID rules to communications to not factor in standard coding and documentation requirements. Simply to verify the appropriate level of service. Be on the watch that behavioral health and high-risk elective care will also have audit exposure. Many health systems have been sensitive and realize that documentation and coding is key to clinical and financial responsibility.

Do you have a technology solution in place to help meet these new audit challenges?

The most effective way for providers to prepare for telehealth audits, or any other type of audit is to implement a comprehensive audit management and response process. This will include identify dedicated staff and resources to receive, evaluate and respond to the audit requests and implementing a core audit management platform to make the entire process more efficient and effective. Today's audit solutions have the ability to aggregate multiple points of data form disparate systems to automate and streamline the audit response process.

The main benefit of implementing a comprehensive audit management solution is to protect valuable insurance reimbursement dollars. This has become even more important with the revenue challenges resulting from the COVID-19 pandemic felt across healthcare providers of all types. Additionally, audit solutions ensure compliance with time sensitive deadlines that often times accompany audit response process. With advances in artificial intelligence and process automation, clinical staff is freed to focus on more value-added tasks such as direct patient care. It is critical for revenue cycle leaders to measure and track the real-time financial impact of audit activity. Audit solutions can indicate current exposure in addition to predicting future exposure based upon relevant clinical indicators. Even if a provider's recent telehealth activity is not currently under audit, it may be a good idea to review submitted claims and plan for future audit activity accordingly.

There are several different audit and denials management solutions on the market today but the features, benefits and costs will vary depending on which solution a provider chooses to implement. When selecting a new platform there are several critical pieces of functionality that should always be included in a new solution. Possibly the most important is full interface connectivity between the audit and denials platform and other related solutions across the enterprise. The audit solution should be able to import claims, remittance and electronic documentation requests, while exporting billing indicators and claim referrals to either release of information or appeals management systems. When fully integrated, over 90% of required data can be sourced automatically without manual data entry.

If available, integrated release of information can be another valuable tool in the audit management and response process. Available electronic document transmissions can include, receiving initial documentation requests and the submission of medical records in response. For the Medicare Recovery Audit community this process is delivered through Health Information Handlers and the esMD Gateway. For Medicaid auditors and commercial payers, custom interfaces with their portals can be developed and integrated within the audit management platform. This capability can result in tremendous saving of time and money over the traditional paper-based approach to audit document transmission.

Having the right workflow tools in place can customize an audit management solution to meet a provider's individual and specific needs. Case management tools include custom account status models, integrated workflows, intuitive work queues and activity notifications as audits move through the response process. With customizable payer contract tools, the solution can be configured to the specific commercial payer audit and denial rules and requirements. This allows for a single platform to manage both government and commercial audit activity. The final piece of required functionality is a comprehensive reporting package. It is important to have access to real-time audit status, worker productivity, and financial impact to the health system.

Blueway Tracker from Bluemark has been an industry leading audit management platform for over a decade and it brings together all of the critical functionality into an easy to use and cost-effective solution. Even in these most challenging times, Blueway Tracker stands ready to help providers defend against all types of insurance audits. To learn more visit

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Bluemark Article: How PFS Leaders respond to COVID-19

By: Lyman Sornberger, Principal with Lyman Healthcare Solutions

This ship has sailed and if in revenue cycle you are scared of your shadow now, wait until you see the ghost of the future in 2021 with COVID-19. The financial losses from the COVID-19 pandemic are not just being felt today but will also have extreme effects on hospital revenues and revenue cycle management well into the future. Without a doubt, COVID-19 has upended the U.S. health care system.

The impact is far reaching and includes nonclinical workforces shifting to work from home models and virtual communication with patients has exploded. In spite of unemployment reaching all-time highs, there is also a shortage of personal in the Patient Financial Services (PFS) sector. Many in the industry feel the desire to get back to how things were, the term normal is often used to describe this former state. However, many aspects of the historical PFS business model are the very things that have left providers vulnerable to the crippling impact of the pandemic.

Moving forward, providers will need to create a "New Normal" in the PFS arena. The new PFS model will require providers to assess and embrace the positive transformations that have been introduced because of COVID-19 and make them policy then assess those activities that have been discontinued and abort them entirely. The traditional PFS model of inhouse or outsourcing may no longer be applicable for the future and will in all likelihood be ill equipped to respond to the huge demand ahead. This is an opportunity for providers to use this unprecedented environment to correct what hasn't worked and create new strategies, processes and goals. The thinking needs to shift to concepts such as process automation, account monitoring, labor savings and stronger overall management tools. Today, many providers are focusing on mitigating the financial impact of COVID-19 on their patients, staff, and overall businesses. But few have had the opportunity to strategically assess, "what comes next", and the time to do this is now.

The purpose of this article is to review the "New Normal" of Patient Financial Services. Specifically, the return of non-urgent workers, coping with the second wave of COVID-19, new technology tools, vendor relationships, and responding to health care economic recovery both operationally and to the future management of the health care delivery system. It is understandable that providers are in somewhat of a pause with a response to the COVID-19 impact with PFS. However, reality will soon set in and with it the historical RCM management scrutiny Including: cash is king, days in receivables, increasing aged AR, sky-rocketing costs, and lower patient satisfaction.

One thing that will not change is the fact that nothing happens in the PFS function without a cause and effect with continual measuring and monitoring. Before diving more deeply into the strategies let's have a quick review of the most relevant impacts on health care providers.

  • Unemployment is now at 11% and demand will increase for evaluating the uninsured and underinsured. We spent the last few years looking at balance after insurance and now will revisit intensely those that have no coverage.
  • Denials will increase, maybe not today with the sensitivity to COVID-19, but without question providers will need to have a strategy for denials management and to effectively collect every "dollar owed" for services rendered.
  • Telehealth will add a whole new dynamic to Patient Financial Services, with increased denials, and audits in the near future.
  • Patient collections will be a challenge with a focus on consumerism, technology, and patient sensitivity to the providers brand.

Without question the downstream effects will be more audits and law suits. Today, the flood gates are open but as we all know historically that they can be abused for various reasons and often not deliberately. Does anyone remember RAC in PFS? COVID-19 could make that challenge look like nothing ever happened back then.

As responsible finance leaders we must respond to the challenges posed with COVID-19 both today and tomorrow. It begs the question with providers and partners are we tracking the pandemic challenge and more important do we as providers have a strategy to manage the future?

Today we have a crisis in healthcare responding to this particular virus with clinicals, financial, and operations. We were not prepared and do not have a resilient health care revenue cycle model to respond to today and let alone tomorrow. All said providers are not prepared for the second or third wave of COVID-19 and flu epidemic in the fall of 2020 and the first half of 2021. Couple that with the increase in the uninsured, change in health care plans, reimbursement that does not cover cost, and patient consumerism.

A few questions for your strategy to offset the clinical and financial impact:

  • How automated is your self-pay management process?
  • Can you efficiently and securely assign work, manage productivity, and monitor account flow?
  • Can you track staff effectiveness and promote tools to enhance communications and collaboration internally and externally?
  • Do you have revenue cycle analytics tools to trend key performance indicators?
  • Should you revisit options with partners who provide established tools that will complement the new world of revenue cycle management?

In our immediate response we know patients avoid healthcare facilities unless absolutely necessary for clinical care. Visits are done now by smartphones, laptops, transformed hotel rooms, parking lots, sports arenas, tents, and the list goes on. Sounds pretty flexible for now and I am a fan of integration of all areas to the continuum of care for the patient's financial situation and overall wellness.

What are the facts that we are acting on today and even more so tomorrow?

The American Hospital Association estimates that hospitals are slated to lose $300 Billion in revenue in 2020 as a result of COVID-19. As COVID-19 surges this numbers will continue to rise. Although elective services have started to resurface in certain geographic areas, it fails to cover the financial and consumerism exposure with COVID-19. The traditional top inpatient service that account for 50 percent of the total payments made to hospitals are at a 99% decrease. Add to that, patient confidence to return for these procedures is at an all-time low putting in further jeopardy this much-needed revenue stream now and after the pandemic subsides.

Healthcare providers need to re-invent their overall strategy to respond to these enormous financial losses. "Bricks and mortar" expansions are on hold, revisiting staffing models will be key, and rethinking automation options and support models will be on the front burner.

COVID-19 has placed the entire economy into a recession and not just with healthcare. According to the Urban Institute it is anticipated that 2.9 million individuals will become uninsured by the end of 2020 due to job losses related to the pandemic. Other projections have that number as high as 10 million people. Add that to the currently unemployed of 30 Million, that will result in even more Medicaid eligible beneficiaries.

This shift will not only create a dramatic financial burden but also a significant change in the providers payer mix creating more demand for different patient billing tactics. Providers are forced to rethink their management of the uninsured and underinsured, further stressing the need for technology, and third-party options. In recent years healthcare providers were required to place a great focus on self-pay patient accounts with high deductible plans. But the COVID-19 pandemic is forcing hospital management to revisit their self-pay strategies during the health care economic recession.

Whether we hate the new phrase "new normal" or not, there is no question that health care revenue cycle will not be the same in the years to come even after COVID-19 passes. But there could be a silver lining in that we will rethink and evolve the traditional models. These new models will encourage more automation and technology, different consumerism options to patients and providers, enhanced management tools, rebound reimbursement, and a decrease in costs to offset COVID-19 losses.

Ultimately, the "Next generation" of healthcare will require that we revisit the "old concepts" and become extensively digital systems of care, more interconnected, automated, community engaged, fiscally responsive, and more open to outside solutions. This concept is not necessarily new but because of COVID-19 it is now on "steroids" due to the clinical and financial impact. Historically with clinicals the technology has been around the "patient experience" but this virus has required us to improve the patients financial experience as well. Are you in front of that ship?

Working smarter not harder is the new world of Revenue Cycle Management

Technology has been a part of the patient financial services process for the past two decades. For those hospitals that have chosen to insource assistance program eligibility and enrollment, technology has been used for program screening, account processing and outcome reporting. This key functionality is still important today, but to truly excel in a post COVID-19 environment additional technology must be embraced and deployed. Specifically, self-service tools will be needed to support contactless engagement models. Evolved enrollment processing capability, featuring more automation and less manual actions, will enable stretched resources to handle more accounts. Highly sophisticated management tools and reporting will need to be in place to ensure that the patient financial services team operate at the highest level of efficiency and no reimbursement opportunities are missed.

For the foreseeable future, direct contact with the patient population will be a challenge, patient financial services staff may continue to operate remotely and contactless requirements will be in place. Self-service portals provide patients with a web application for eligibility screening and enrollment into available assistance programs. This technology takes advantage of email, text and QR codes to optimize patient outreach and drive higher levels of engagement. It also allows patients to securely self-screen, supply application information, submit required documentation and direct message with their financial counselor. The most effective solutions are optimized for use with smartphones and tablets and can be branded with the hospital's name and logo to enhance the overall patient experience.

Core account processing tools are at the heart of the evolved PFS process. These tools are designed to quickly and accurately assess an individual's eligibility for available assistance programs and then move the account through the appropriate workflows to ensure program enrollment. To effectively handle the expected increase in uninsured patient volume, new technology will need to be leveraged across the entire eligibility and enrollment process. The most efficient enrollment process will leverage a combination of direct data input and rules-based automation to keep patient accounts moving through the process. Optimized web-browsers will allow date sharing with state-based Medicaid portals to simplify the application submission process.

The combination of managing both the volume of self-pay patient accounts plus a team of financial counselors can be a daunting task for PFS leaders. New technology must come equipped with the most advanced management and reporting tools available in the industry. These tools will allow PFS leaders to identify potential issues before they become major problems. Solutions need to includes a portfolio of standard reports which have been developed and refined through years of client engagements, plus the ability to access the raw data and create their own reports utilizing a simple interface. Typical reports include account status, final disposition, processing cycle-time, and user productivity.

The "New Normal" for Patient Financial Services will include a combination of people, processes and technology. To be successful, revenue cycle leadership must apply all available resources, be open to new operational models and evaluate and embrace new technologies like never before. The healthcare system in this county is both resilient and flexible and I am more than confident that we will rise to the challenges from COVID-19 and form a better path forward as a result.

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Bluemark Welcomes Ginger McDonough

Bluemark is pleased to announce the hiring of Ginger McDonough as Regional Vice President of Business Development. In this newly created role, Ginger will lead the company's business development efforts in the Southeast Region of the US. This addition aligns with a broader corporate strategy to grow the company by expanding our reach into new markets.

Ginger will leverage key industry relationships that she has developed over her career in the healthcare revenue cycle management arena. As a member of the Business Development Team, Ginger will be working closely with Ken Sacks, Partner and Steve Mullin, EVP of Business Development and Marketing on developing an outreach plan and executing key initiatives to drive the company's growth strategy.

Ginger brings over 14 years of experience within the healthcare market to Bluemark. Most recently, Ginger held the position of VP of Business Development for Bolder Healthcare, a full Revenue Cycle outsource firm. Prior to that she was Director of Patient Access with Mary Washington Healthcare in Virginia and Director of Patient Access with Potomac Hospital in Maryland. Ginger holds a BS in Healthcare Administration from Iona College and an MHS in Healthcare Administration from Strayer University.

Please join us in welcoming Ginger to Bluemark.

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BLUEMARK Launches "Full Cycle" esMD

Bluemark now offers Full Cycle esMD for its Blueway Family of audit management and audit response solutions.

Bluemark, LLC, a specialized healthcare technology developer announced that it will now be offering Full Cycle esMD services as part of its Blueway family of audit management and audit response solutions including Blueway Tracker and Blueway Portal. Bluemark developed Full Cycle esMD to take advantage of the bi-directional electronic document communication between the Medicare Recovery Contractors and healthcare providers. Full Cycle esMD, leverages the CMS esMD Gateway and creates a virtual in-box for electronic document requests and automatically triggers the audit response process. With Full Cycle esMD providers can easily and efficiently respond to all types of Medicare audits. Bluemark is a Certified Health Information Handler and has been working with CMS on the testing and rollout of this capability for the past several months.

"Bluemark is pleased to be one of the first organizations to support this new phase in electronic document communication within the Medicare provider community," said Bryan Exner, Bluemark's Chief Operating Officer. "Full Cycle esMD will not only simplify the overall audit response process, but it will improve payment cycle-time, lower provider costs and eliminate errors. In fact, our studies have found that when receiving document requests electronically, providers can save up to five days in the initial stages of the audit response process. This can have a significant impact especially when dealing with time sensitive deadlines."

Full Cycle esMD will be available within Bluemark's Blueway family of audit management and response solutions. Blueway Tracker provides all of the necessary tools to assist providers in efficiently managing and responding to Medicare, Medicaid, and Commercial Insurance audits. Blueway Portal is one of the few standalone esMD solutions available today and allows providers to immediately begin taking advantage of Full Cycle esMD.

BLUEMARK, LLC, Welcomes New Strategic Advisor

Industry veteran, noted presenter and healthcare revenue cycle consultant, Lyman Sornberger joins Bluemark as Senior Strategic Advisor.

Bluemark, LLC, a specialized healthcare technology developer, is pleased to announce the addition of Lyman Sornberger in the role of Senior Strategic Advisor. Lyman is the President and CEO of Lyman Healthcare Solutions a leading provider of revenue cycle consulting services for hospitals and health systems across the country. Lyman also spent many years on the provider side in revenue cycle leadership positions with the Cleveland Clinic and University of Pittsburgh Medical Center. Lyman's specialty is business process improvement and optimizing technology within the revenue cycle. As a Senior Strategic Advisor, Lyman will assist Bluemark in refining its solution positioning and go to market strategy in addition to identifying new client engagement opportunities for both its MAPS eligibility and enrollment solution and the Blueway audit and compliance family of solutions.

"We are delighted to welcome Lyman to the Bluemark organization as a Senior Strategic Advisor" said Ken Sacks Chief Executive Officer. "Lyman brings over 35 years of leadership experience on both the provider and vendor side of the healthcare revenue cycle environment. Not only will he help us to identify new opportunities, he will also provide valuable insight into our future product development strategy."

Lyman has worked with over a hundred clients on full revenue cycle operations reviews, investment counseling, best practice implementation and management, ICD 10 conversions, and Epic implementations. He has also worked with several revenue cycle vendors assisting them with developing sales and marketing strategies, advertising campaigns and website development. Lyman is a noted industry speaker and is a member of HFMA, AAHAM and HIMSS. Lyman holds a Master's Degree in both Non-Profit Management and Healthcare Administration from the University of Pittsburgh where he also earned his Bachelor's Degree. He is also a veteran of the U.S. Army where he performed honorably as a Medic.

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