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changes

Article 03.10.2023 Dean Dorton

On January 30, 2023 the Biden Administration announced the anticipated ending of the Public Health Emergency declarations. These declarations are set to expire on May 11, 2023. Due to heavy reliance on 1135 Waivers throughout the time that the Emergency extended, the ending of the Public Health Emergency will have a large impact on Hospitals. 1135 waivers are used to waive various administrative requirements to increase access to medical services during a time of national emergency. Now that the emergency is coming to an end, healthcare entities should take steps to ensure their compliance with laws and regulations while returning to normal operations.

It will be important for hospitals to review their policies and procedures to ensure compliance with regulations and standards that will be changing and to update these policies if necessary. It is important to note that some waivers end at the conclusion of the Public Health Emergency, while others end 151 days following the conclusion of the Public Health Emergency.

Prior to May 11th, administration and leaders in each department throughout hospitals should be asked the following questions in order to ensure that they are prepared for the coming changes:

  • Is your department currently relying on any waivers that are still in effect?
  • Is your department currently relying on any waivers that have expired?
  • Has your department developed a plan and sent out communications to wind down any reliance on waivers by the expiration date?
  • Does your department understand state laws in areas that will be affected when waivers default back to state laws after expiration?

CMS and others have released guidance on the current 1135 waivers and on the end of the Public Health Emergency in order to help prepare practices. For hospitals that are highly reliant on 1135 waivers, this guidance will be key to preparing for a return to normal operations. Linked below are a few articles that will provide support in this area.

COVID-19 Emergency Declaration Blanket WaiversCoronavirus Waivers & FlexibilitiesUnwinding & Returning to Regular Operations after COVID-19

Adam Shewmaker | Healthcare Consulting Director
ashewmaker@ddafhealthcare.com
502.566.1054

Filed Under: Healthcare, Industries Tagged With: 2023, changes, COVID, Healthcare, Public health

Article 01.26.2023 Dean Dorton

Well, I checked again today and normal is still missing from the dictionary for most of us. Post-COVID-19 pandemic has taken its place and in the space for definition, there’s a big, bold question mark! A lot is still in flux. Nonprofit organizations continue to deal with upheaval in staffing, accessibility, and resources. Federal and state funding assistance related to the pandemic has dried up and mandatory loan repayments are upon us. Economic uncertainty and rising costs seem to be significantly spooking the small to mid-sized donor pool.

The current economic situation is creating a cash crunch for many nonprofits, with the potential of a future cash crunch to impact many more. The time to prepare is now!

Gain control of the situation and better position your organization with the following action steps:

Secure a line of credit that will cover 2-3 months of payroll & benefits

Providing service is what you do, so providing employees with stability is essential to a speedy recovery from slumps in cash receipts. If you have an established and positive banking relationship, start by contacting your relationship manager to understand that institution’s application process and associated fees. All banks and financial institutions are not created equal when it comes to lines of credit for nonprofit organizations. Some require collateral or a personal guarantee. Some will charge an annual maintenance fee or a fee for failing to use the line periodically. Therefore, research options at other financial institutions even when you have a strong local relationship and consider the relationship as just one variable in your final decision. Leverage the influence of your board. Ask board members for referrals to their financial institutions. Reach out to state and national organizations that support nonprofits, like KNN, for referrals to resources known to be generous and fair to organizations your size. Established nonprofits can generally qualify for an unsecured line of credit that is sufficient to cover 2-3 months of payroll and benefit expenses. If denied in a first pass, ask why and continue to shop around while you work on eliminating the barriers to your success.AMA – 2023 Code changes and descriptors

Monitor working cash reserves each week

Determine what the monthly average total cash out is for the organization. This doesn’t need to be precise or require a sophisticated accounting system. If your payments are issued from one primary operating checkbook, just see how much went out of the checking account for the past year and divide it by 12. Apply common sense to the result. If it seems too high, make sure there wasn’t an unusual transaction or a bank transfer/adjustment that was mistakenly captured in your numerator and rework the math. If it seems too low, perhaps you have a second bank account used for payroll or other primary expense and the same exercise needs to be applied to that account to get a final result. Once you have confidence in the monthly average spend of the organization, determining working cash reserves is a quick calculation. Begin with cash in the bank. Add any investment that you can cash out within a week (in the event of an emergency) and subtract the bills you currently owe. Divide the result by monthly spend. If the organization has less than 3 months of working cash reserves, measures should be taken to move the needle.

Vet expenses before they occur

Budgeting is an important part of long-term sustainability. A cash crunch, however, is not the time to fall back on “it’s in the budget” as justification for incurring a cost. Each commitment should be laid up against the simple outcome of short-term mission sustainability. Invest in paying the bills that keep the organization open and aligned with its core commitment to the community it serves. Nonprofits depend on public trust. Breaking that trust by failing to deliver on the mission will only jeopardize future cash flow and could create a negative cycle that can’t be remedied. Now is the time though to delay expenditures that go above and beyond the core commitment and those that are intended to create organizational growth. The investment in those expenses will result in better returns when they can be initiated from a place of cash stability. Be patient and focused in expense management until the organization is beyond its cash crunch.

Become a master of timing

Know when bills are due and what the consequences are for late payment. Avoid incurring interest and late payment penalties but also don’t be tempted to pay anything early because it’s small or there is money in the bank at the time bills are being paid. Having the cash available right now is of greater value than a minimal discount or the slight goodwill gained by early payment. Take the time to know your recurring vendors and negotiate for better terms or payment plans whenever you can. If you cannot pay all your bills by their due date, pay in full those that cannot be delayed without penalty and then negotiate a plan to pay those that remain within a reasonable period of time. Try to avoid drawing on the line of credit for accounts payable so that you have confidence in the organization’s ability to manage payroll.

Examine your cycle of cash receipts. Are there any gifts, grants or sales that you can encourage an earlier payment on with prompt or accelerated reminders, invoices or phone calls? Take that action. If you need to draw on the line of credit, repay that balance as quickly as you can to maintain its availability and mitigate finance charges.

Do the deep thinking and act

Is this cash crunch a timing issue or a systematic one? Consider revenue sources and their sufficiency to generate the cash needed to cover cover investment in the expansion of your mission beyond current payroll and operating expenses. Expanding the mission may mean service to a wider base or diversification of services currently offered. It may mean developing the infrastructure to pivot more quickly to the changing needs of your specific community. Regardless of what it means to your organization, just enough isn’t a healthy long-term vision for cash management. Review receipts and expenses for the past several years and determine if your post-pandemic receipts can realistically outpace the organization’s basic cost of operations. If not, consider promptly engaging the board in strategic planning to sustainably reframe the organization.

If timing is the issue, take action to move further away from the cash crunch cliff. Make reserves part of the budget until you’ve reached a cushion equal to 6-12 months of monthly average spend. This reserve and the line of credit should give you the bumper you need to weather typical economic cycles and cost increases while you retool your revenue model. To get there faster, consider a special sustainability campaign or solicitation, a targeted grant or partnership that will displace unrestricted resources so they can be set aside for the future. Share resources with other organizations. Expenses like staffing, fixed assets, and marketing can often be leveraged by partnering with a complimentary organization or a for profit that is looking for a sponsorship opportunity. Engage in solid, legally vetted agreements with clear oversight to keep these relationships healthy and beneficial to both parties. Finally, recognize that every new initiative has an element of overhead and draws resources (time) from core operations. Be sure that new ideas can clearly advance your mission and be funded before going too far into the process of can become planning and implementation. In the absence of feasibility and measurement, great ideas leading drain on cash and are difficult to unwind in a cash crunch.

Remain optimistic

Colin Powell said, “Perpetual optimism is a force multiplier.” Don’t underestimate the power of that math.

A cash crunch is unfortunate, but it’s a risk of doing business. As they say “cash is king!” Pay attention to your organization’s spending. Be good stewards with the resources you control. Pay attention to your organization’s key revenue streams. Be hone st with your board about your organization’s cash situation. Don’t be afraid to ask for help. By managing resources and relationships well, you will be able to successfully outsmart a cash crunch.

Kaydee Ruppert | Associate Director & Nonprofit Industry Advisor
kruppert@deandortonstg.wpenginepowered.com
859.425.7730

Filed Under: Industries, Nonprofit & Government Tagged With: 2023, changes, finances, nonprofit, planning, strategy

Article 12.21.2022 Dean Dorton

The law applies to entities doing business in California or collect personal information from California consumers and meet any one of the following criteria:

  • As of January 1, of the calendar year, the company exceeded $25 million in gross revenue in the preceding calendar year.
  • The company buys, sells, or shares the personal information of 100,000 or more consumers or households.
  • The company derives 50% or more of its annual revenue from selling or sharing consumers’ personal information.

If the criteria is met California residents have the following rights to:

  • Opt-out of sharing personal information
  • Opt-out of certain used and disclosures of sensitive personal information, examples: SSN, DL, geolocation, race, health data
  • Correct inaccurate personal information
  • Know more details of business’s information practices
  • Have options regarding automated decision-making

Increased obligations on businesses include:

  • Requirements related to data retention, data minimization, purpose limitation.
  • Requirements to pass deletion requests to service providers, contractors, and third parties the business has sold or shared information.
  • Requires additional contract provisions with service providers, contractors, and third parties.
  • Possibly increasing auditing requirements, performing annual cybersecurity audits, and providing the California Privacy Protection Agency with regular risk assessments.

The enforcement and penalty goes beyond and modifies the California Consumer Privacy Act (CCPA) in the following areas:

  • Creates and transfers rulemaking and enforcement from the California attorney general to the California Privacy Protection Agency, which is a new state agency.
  • Removes the 30-day cure period.
  • Triples penalties for violations involving minors under 16.
  • Expands the types of data breaches that are considered within scope of the data breach privacy right of action to include: breaches of a username or email address combined with a password or security question and answer that would permit access to an online account.

California may be leading in data privacy laws, but other states are moving in this direction. Other states include Colorado, Connecticut, New York, Utah, Virginia and Washington.

To meet various state data privacy requirements, we suggest doing the following:

  • Know your data – where is it, what is it, who has it.
  • Have a holistic data privacy program. Identify the highest bar (likely CPRA) and use this measure for all privacy processes.
  • Ensure a plan is in place or has been executed to meet the more stringent privacy requirements.
  • Stay well-informed of changes to laws.

Subscribe to Dean Dorton Insights to stay up-to-date with the latest regulatory changes.

Kevin W. Cornwell | IT Audit Associate Director
kcornwell@ddaftech.com
502.566.1011

Filed Under: Healthcare, Industries Tagged With: 2023, authorization, changes, Healthcare, ruling

Article 12.14.2022 Dean Dorton

On December 6th, CMS released the proposed rule outlining systematized prior authorization pathways for healthcare services rendered by providers and hospitals. The proposed rule outlines the goals to improve the prior authorization process and drive more transparency and efficiency to all stakeholders involved including payers, providers, vendors, and patients. Current prior authorization processes have created  burden on payers and providers and is a major source of burnout for providers, thereby possibly impacting the health inefficiencies of patients in the potential delay of care

The burden of prior authorization has been well documented in the American Medical Association (AMA) Study released in December 2021.  The study indicated not only had there not been an increase in prior authorization efficiency, it had actually become worse.1  The study outlined the operational time, human capital and lack of technology impacts that negatively effect the efficient delivery of care.1   Furthermore, physicians reported that most prior authorizations are completed via phone calls and faxes, with only 26 percent reporting that they have access to an EHR system that supports electronic prior authorization for prescription medication.2

The proposal currently outlines requirements that would be applied to payers:

  • Build and maintain a Prior Authorization Requirements, Documentation, and Decision (PARDD) API to automate the process for providers to determine whether a prior authorization is required, identify prior authorization information and documentation requirements, and facilitate the exchange of prior authorization requests and decisions from providers’ electronic health records (EHRs) or practice management systems
  • Include a specific reason when they deny a prior authorization request
  • Send prior authorization decisions within 72 hours for expedited (urgent) requests and seven calendar days for standard (non-urgent) requests
  • Publicly report certain prior authorization metrics annually by posting them on their website or through publicly accessible hyperlinks3

CMS is seeking comment related to the proposal, including alternative time frames for prior authorization decisions. Comments on the rules are to be received March 13, 2023.

Federal Register Publication

1American Medical Association (2021). AMA Prior Authorization (PA) Physician Survey Results.
2American Medical Association  (2021). AMA Measuring Progress in Improving Prior Authorization.
3AMGA Advocacy News

Eric Riley | Healthcare Consulting Director
eriley@ddafhealthcare.com
859.425.7704

Filed Under: Healthcare, Industries Tagged With: 2023, authorization, changes, Healthcare, ruling

Article 12.14.2022 Dean Dorton

Changes to in-patient evaluation and management (E & M) service codes for 2023 are coming. The changes will be effective January 1st, 2023. These changes follow the outpatient service coding updates implemented on January 1st, 2021. A recent AAPC review noted the following lessons from the 2021 implementation:

  1. The change was harder than expected
  2. Explaining the updates and changes was not as smooth as envisioned
  3. There are still gray areas to be addressed
  4. Applying the guidelines when reviewing notes is not as easy as counting elements
  5. The changes were still an improvement and a good thing

The updates align the method of assigning levels of service (LOS) for in-patient services with those introduced on January 1st, 2021, in the outpatient setting. The history and physical exam components will be documented at the providers discretion, and will not be factors in assigning the final level of service. The documentation must however support the medical necessity of the service.

We are mindful of the need to prepare physicians and non-physician practitioners for this change in the coding of their professional services. A clear understanding of these changes is imperative to avoid the possible compliance pitfalls that may lie ahead. While change is disruptive, this transition promises to provide greater ease for physicians with their billing practices.

The table below gives a brief snapshot of the pending changes for the respective in-patient service codes. The time thresholds for each code are displayed with the codes below. It is important to note that emergency department (ED) codes and guidelines have been revised. No time thresholds apply to ED codes.

Deleted Codes

Deleted codes include:

  • the previous hospital observation codes (99217 to 99220).
  • level one codes for consultations services (99241 and 99251).
  • nursing facility code 99318, and
  • prolonged services codes 99354 to 99357.

https://deandorton.com/wp-content/uploads/2022/11/Revised-EM-Service-Codes.png

New for 2023

The initial (99221-99223) and subsequent (99231-99233) in-patient service codes will also now be used for observation services. In addition, new prolonged services codes have been added for the in-patient and outpatient settings. Code 99417 was added for outpatient, home or residence service encounters. Code 993X0 was added for inpatient, observation or nursing facility services encounters. The appropriate guidelines for all these services have been updated accordingly.

Dean Dorton has experts available to assist your practices in implementing an educational plan, and partnering with you to navigate these regulatory changes. Please do not hesitate to reach out to our experienced team. We are committed to serving any of your healthcare needs.

Sources:

  1. Lessons learned from the E/M code changes 
  2. Compliance Today; September 2021: A review of the impact of the 2021 E/M coding changes in the office and outpatient setting
  3. AMA – 2023 Code changes and descriptors

Brandy Montgomery | Healthcare Consulting Manager
bmontgomery@ddafhealthcare.com
502.566.1037

Filed Under: Healthcare, Industries Tagged With: 2023, changes, Codes, Coding, E/M, Healthcare

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