Mitigating Impact of Growing Regulatory Burdens on Physician Practices

By Matthew D. Bayley, M.D., Group President, Conifer Health Solutions
Twitter: @coniferhealth

Each year the Medical Group Management Association (MGMA) surveys hundreds of group practices to assess how industry regulations are impacting them. Just as in previous years, the most recent survey shows things are getting worse, not better. Nearly nine in 10 respondents said their practice’s regulatory burden has increased. Ninety-seven percent said that if it weren’t for regulations, they would be able to transition resources to patient care.

Of all burdens reported, those ranking highest were prior authorizations, surprise billing, Medicare Quality Payment Programs (MIPS/APMs), and audits and appeals. The results are understandable considering the amount of time and vast resources practices spend managing processes around these burdens. Besides extra work required of staff, these burdens place undue pressure on a practice’s bottom line.

Since practices are already being asked to do more with less, they need a way to achieve compliance while continuing to provide high-quality care. And they need to be able to do it without adding staff or hours to the day. That’s why many have chosen to partner with industry experts to help. The following outline provides four opportunities to reduce regulatory burden through outsourcing.

Prior Authorizations

According to the 2022 CAQH Index report, a manual prior authorization takes an average of 20 minutes to conduct, making it one of the most time-consuming administrative transactions to conduct. By adopting electronic prior authorizations, providers could save 11 minutes per transaction while also potentially saving the industry $449 million a year. And since the average practice completes 41 prior authorizations a week, saving 11 minutes per transaction would add nearly eight hours—an entire day—back to their schedule.

Prior authorizations are also a barrier to optimal care. A 2022 survey by the American Medical Association found that more than nine in 10 physicians say the prior authorization process causes delays in care. Eighty-eight percent said the burden from prior authorizations is “high” or “extremely high.”

Outsourcing prior authorizations can help alleviate this burden on practices. The most effective partners are those that use automation technology to streamline the prior authorization process, reducing turnaround times and ensuring patients are able to get the care they need when they need it. This, in turn, can help improve the patient experience and enhance patient satisfaction and provider loyalty.

In addition to faster prior authorizations, outsourcing can help reduce write-offs and surprise bills by ensuring the process is completed accurately and that no information is missed.

Surprise Billing

As of November 2022, the No Surprises Act had prevented nine million surprise bills. While the bill has worked as intended—although some say it favors payers—it has placed a significant burden on practices as they face a backlog of payments sitting in the dispute resolution process.

Although the legislation will most likely continue to be scrutinized and refined, outsourcing can help practices by strengthening revenue cycle processes that promote price transparency, self-pay collections, and streamlined patient payments. Digital tools like payment portals and mobile payments can help make paying easier for patients. And solutions like propensity to pay analytics and patient responsibility estimations give practices the opportunity to talk with patients about what they owe and collect full payment earlier in the revenue cycle.

Medicare Quality Payment Programs (MIPS/APMs)

Quality and alternative payment programs like MIPS and APMs are designed to reward cost-effective, high-quality care. While the incentives can be significant, the reporting burden can be as well. Just as with other areas of the revenue cycle, many practices don’t have the resources to dedicate to comprehensive quality reporting. This presents an ideal opportunity to outsource.

Besides helping practices understand which programs they are eligible for, outsourcers can help guide the practice toward the most cost-beneficial program based on their unique population makeup, services provided, number of providers, and other factors. Once enrolled, the right partner can help with every aspect of measuring, analysis, and reporting. It’s a great way to stay compliant while optimizing reimbursement.

Audits and Appeals

For practices participating in CMS’s risk-adjustment payment model, high-quality coding is critical to achieving maximum reimbursement. It can be challenging enough for practices to get reimbursed. Having to pay penalties and return payments by way of “takebacks” is agonizing. And those takebacks have become a growing burden. One review by the Office of Inspector General (OIG) discovered that Medicare had overpaid providers by $54.4 million for 18,647 claims due to incorrect patient discharge status codes.

Incorrect coding is a problem for many practices, especially those that have struggled with turnover and labor shortages in their coding teams. Finding experienced coders is increasingly difficult since coding is a job that can be done remotely. Instead of competing with local healthcare providers, practices have found themselves competing with providers across the country—many of whom can pay higher salaries and large sign-on bonuses.

This makes coding a particularly attractive outsourcing option. Many vendors have a more extensive network of resources and access to high-volume recruiting divisions. This means they not only have a larger pool of revenue cycle experts to pull from, but also the ability to scale to fill vacancies more quickly. They also have the resources to provide ongoing training and certification, so their coders are always up to date on the latest regulations. This can help reduce errors, takebacks, penalties, and denials.

Preparing for the future while dealing with the present

As federal and state organizations push for reduced costs and improved outcomes, practices will continue to face ongoing regulations that put added pressure on their staff and their bottom lines. Outsourcing can help alleviate these pressures while ensuring that practices achieve long-term financial viability, regardless of what new regulations lie ahead.