CSA Online First

CSA Online First is a weekly blog featuring insights from CSA members themselves.

Edited by Rita Agarwal, MD, FAAP, with contributions from CSA’s Committee on Professional and Public Communications, Online First is a place where knowledge and opinion from any one of our 3200 plus physician-anesthesiologist members can be shared, discussed and deliberated to advance the specialty of anesthesiology, the practice of medicine and society in general.

"Better solutions to difficult problems are usually made when all sides are heard."

Steven Goldfien, MD


Revenue Cycle Management Basics for Anesthesiologists: Part 3

  • Doyle, Christine, MD, FASA
| Nov 29, 2021

Christine-Doyle-MD-FASABusiness Models, Mergers & Acquisitions, and Legal Issues

Although much has been made about the difference between non-profit and for-profit healthcare systems, there is really little difference when it comes to the RCM process. Both will work to optimize the process, streamline coding, and attempt to minimize the time between the patient care and the payment. The major difference has been the ability to invest capital into the process, which has traditionally been easier in for-profit systems.

The use of the EHR makes it much easier to collect the data for RCM usage. Even before this, larger organizations were better able to implement Clinical Documentation Integrity (CDI) teams as part of the evolution of Medical Records into Health Information Management. 24  Until the push for implementation of EHRs as part of 2009’s HITECH Act, only the larger and for-profit (or very well endowed academic) organizations were able to make the capital investment. Current CDI efforts, however, have reached a maturity level so that continued improvements in case mix are near a plateau. 34

The continued run of mergers and acquisitions generally contributes to efficiencies in RCM.  It’s not, however, as simple as just having the new facility switch to the parent facility’s system. Each facility should start by stabilizing their current processes, then standardizing their processes, and finally consolidating the process. It is important to remember that this, like almost every other aspect of business, is a process, not an endgame. Consolidation should lead to streamlined patient experience (and thus improved patient satisfaction), greater nimbleness in responding to external pressures, and an overall reduction in costs. 41  Continued merger and acquisition activity also has potential for negative impact, particularly with concerns that both horizontal and vertical provider consolidation raises prices, and that payer consolidation lowers payments (although does not necessarily decrease premiums). The Federal Trade Commission (FTC) has cited several constraints in their ability to review and enforce anti-trust laws, particularly on non-profit hospitals. 42

The otolaryngology department at Henry Ford Health System noted that general coding teams, responsible for a wide range of specialties, tend to have more variability in the coding process, leading to submission of inconsistent or incorrect claims. They implemented a specialty-specific team for their service line, which included training sessions with coders and practitioners together, fostering better understanding of the process for both sides.  Although they saw no significant change in the dollars collected, every other metric improved, particularly days to completion of coding, and days in A/R, which dropped by 50%. 43

Optimizing the RCM for a facility or health system is not without risks, however. There are legal precedents and ongoing lawsuits about billing and antitrust issues in California and other states. 

A class-action lawsuit was filed against Sutter Health by the UFCW & Employers Benefit Trust (UEBT) and the Attorney General of California in 2014. The anticompetitive practices identified in the lawsuit included Sutter’s expanding their market power in Northern California, and then using that power to negotiate significantly higher healthcare prices than would have been charged in a more competitive market. Sutter denies the claims and has pointed to data showing that it actually charged less for inpatient care compared to other hospitals in the region (including Kaiser Permanente, Dignity, and Adventist). Nevertheless, a $575M antitrust settlement has been approved. 44,45

Sutter’s issues have continued. The Department of Justice announced a $90M settlement under the False Claims Act for care provided to Medicare Part C (Medicare Advantage). The government alleged that Sutter Health, including both hospitals and affiliated clinics, submitted unsupported diagnosis codes for certain patient encounters, and that once they were aware of the error, failed to take sufficient corrective action. 46

Prime Healthcare, along with their founder and CEO, Dr. Prem Reddy, agreed to pay $65M to settle allegations that 14 of their hospitals knowingly submitted false claims by admitting patients who required less costly outpatient care, and by billing for more expensive patient diagnoses. This settlement was issued in 2018, for patient care that occurred between 2006-2013. The statement by the Department of Justice specifically mentions including complications and comorbidities as part of upcoding practices.  Prime Healthcare, along with Dr. Reddy and Dr. Siva Arunasalam, settled with the DOJ in 2021 for another alleged violation of the False Claims Act as well as illegal kickbacks paid to Dr. Arunasalam. In addition, Prime and Dr. Reddy have entered into a new Corporate Integrity Agreement with the HHS-OIG. 47,48

Stanford Healthcare is currently in the midst of a lawsuit by the Department of Justice for alleged fraud, in excess of $468M. Of note, the complaint alleges that the scheme began in about 2008 when the “newly implemented ‘EPIC’ electronic medical record system came into use.” The case is currently before the Ninth Circuit District Court. 49,50

Future Directions/Conclusions

The RCM process continues to evolve, as providers and payers alike play the game.  New rules from CMS appear annually. Healthcare continues to shift towards Value Based Purchasing instead of Fee For Service or even DRGs. 

One of the most significant changes in recent years was the passage of the No Surprises Act. 51-53 Part of the Consolidated Appropriations Act of 2021, part 1 of the interim regulations were posted July 1, 2021, and they take effect September 13, 2021.   Key components include

  • insurance plans disclosing the Qualifying Payment Amount (QPA) and the methodology by which it was calculated with the provider/facility,
  • notice and consent which includes a good faith estimate of the amount that a provider may charge the patient, even if they intend to bill the plan or coverage directly.

Recent reports in the popular press have been shaking the business of healthcare.  UnitedHealthcare strongly influenced the report written by Yale researchers about out of network billing, which in turn strongly influenced Congress. Questions about the integrity of the research have not been answered. 54  Early evaluation of the Merit-Based Incentive Payment System (MIPS) scores showed limited evidence that a better score was associated with lower rates of hospital complications, and noted that “the main problem with MIPS may not be whether the incentives are large enough to influence physician behavior but rather whether the MIPS quality score is scientifically valid and measures physicians’ contribution to outcomes.” 55,56  And The New York Times reported on hospital and insurer prices, noting that sometimes “insured patients are getting prices that are higher than they would if they pretended to have no coverage at all.” 57

The modern history of healthcare has seen a variety of attempts to control rising costs, with increasing demands by insurance payers and government agencies for specification, systemization, and specialization. This has in turn increased the amount of data to be analyzed, which leads again to systems and agencies with their own biases and agendas. Since data gathered by these systems will be used to justify system changes, gaming the system changes the rules of the game.

How does this relate to Informatics?  It’s all about that data…

24. Russo R. Documentation and Data Improvement Fundamentals. Documentation and Data Improvement Fundamentals / AHIMA, American Health Information Management Association [Internet]. 2004 Oct 15 [cited 2021 Aug 15]; Available from: http://library.ahima.org/doc?oid=60174

25. Grant KB. You Might Want to Get a Second Opinion Before Paying That Medical Bill [Internet]. NBC News. [cited 2021 Aug 31]. Available from: https://www.nbcnews.com/business/consumer/it-s-time-get-second-opinion-paying-medical-bill-n545626

26. OIG. Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010  (OEI-04-10-00181; 05/14). 2014 May;(OEI-04-10-00181):44.

27. Pollitz K, Jan 20 DMP, 2021. Claims Denials and Appeals in ACA Marketplace Plans [Internet]. KFF. 2021 [cited 2021 Aug 31]. Available from: https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/

28. Simborg D. DRG Creep:  a new hospital-acquired disease. New England Journal of Medicine. 1981 Jun 25; 304(26):1602-1604.

29. Román P, Ruiz-Cantero A. Polypathology, an emerging phenomenon and a challenge for healthcare systems. Revista Clínica Española (English Edition). 2017 May;217(4):229–37.

30. Tinetti ME, Fried TR, Boyd CM. Designing Health Care for the Most Common Chronic Condition—Multimorbidity. JAMA. 2012 Jun 20;307(23):2493–4.

31. Wei MY, Luster JE, Chan C-L, Min L. Comprehensive review of ICD-9 code accuracies to measure multimorbidity in administrative data. BMC Health Services Research. 2020 Jun 1;20(1):489.

32. Carter GM, Newhouse JP, Relles DA. How Much Change in the Case Mix Index is DRG Creep? [Internet]. Rand; 1990 Apr. Available from: https://www.rand.org/content/dam/rand/pubs/reports/2007/R3826.pdf

33. Steinwald B, Dummit LA. Hospital Case-Mix Change: Sicker Patients Or Drg Creep? Health Affairs. 1989 Jan 1;8(2):35–47.

34. Ericson C. Is Case Mix Index Still a Relevant Key Performance Indicator? | Journal Of AHIMA [Internet]. 2021 [cited 2021 Aug 29]. Available from: https://journal.ahima.org/is-case-mix-index-still-a-relevant-key-performance-indicator/

35. Sjoding MW, Iwashyna TJ, Dimick JB, Cooke CR. Gaming Hospital-Level Pneumonia 30-Day Mortality and Readmission Measures by Legitimate Changes to Diagnostic Coding*. Critical Care Medicine. 2015 May;43(5):989–95.

36. Surviving Sepsis Campaign (SSC) | SCCM [Internet]. [cited 2021 Aug 29]. Available from: https://www.sccm.org/SurvivingSepsisCampaign/Home

37. Slade E, Tamber PS, Vincent J-L. The Surviving Sepsis Campaign: raising awareness to reduce mortality. Crit Care. 2003 Jan 8;7(1):1.

38. Blood Pressure Toolkit | American Heart Association [Internet]. [cited 2021 Aug 31]. Available from:

39. Diagnosis | ADA [Internet]. [cited 2021 Aug 31]. Available from: https://www.diabetes.org/a1c/diagnosi

40. Liang F-W, Wang L-Y, Liu L-Y, Li CY, Lu T-H. Physician code creep after the initiation of outpatient volume control program and implications for appropriate ICD-10-CM coding. BMC Health Services Research. 2020 Feb 19;20(1):127.

41. Parris R, Schoenvogel M. The Art of Putting It Together [Internet]. Huron Healthcare (Huron Consulting Group); Available from: http://www.huronconsultinggroup.com/~/media/Resource%20Media%20Content/Healthcare/151566%20Print%20Healthcare_WP_RC_ConsolidationStandardization_Final 

42. Schwartz K, Lopez E, 2020. What We Know About Provider Consolidation [Internet]. KFF. 2020 [cited 2021 Aug 31]. Available from: https://www.kff.org/health-costs/issue-brief/what-we-know-about-provider-consolidation/

43. Plawecki AM, Singer MC, Peterson EL, Yaremchuk KL. Impact of a specialty trained billing team on an academic otolaryngology practcice. American Journal of Otolaryngology. 2020 Sep;41.

44. LaPointe J. Judge Approves Sutter Health’s $575M Antitrust Settlement [Internet]. RevCycleIntelligence. 2021 [cited 2021 Aug 31]. Available from: https://revcycleintelligence.com/news/judge-approves-sutter-healths-575m-antitrust-settlement

45. UFCW v. Sutter Health - Home [Internet]. [cited 2021 Aug 31]. Available from: https://www.sutterhealthlawsuit.com/

46. US Department of Justice. Sutter Health and Affiliates to Pay $90 Million to Settle False Claims Act Allegations of Mischarging the Medicare Advantage Program [Internet]. 2021 [cited 2021 Aug 31]. Available from: https://www.justice.gov/opa/pr/sutter-health-and-affiliates-pay-90-million-settle-false-claims-act-allegations-mischarging

47. US Department of Justice. Prime Healthcare Services and CEO to Pay $65 Million to Settle False Claims Act Allegations [Internet]. 2018 [cited 2021 Aug 29]. Available from: https://www.justice.gov/opa/pr/prime-healthcare-services-and-ceo-pay-65-million-settle-false-claims-act-allegations

48. US Department of Justice. Prime Healthcare Services and Two Doctors Agree to Pay $37.5 Million to Settle Allegations of Kickbacks, Billing for a Suspended Doctor, and False Claims for Implantable Medical Hardware [Internet]. 2021 [cited 2021 Aug 10]. Available from: https://www.justice.gov/opa/pr/prime-healthcare-services-and-two-doctors-agree-pay-375-million-settle-allegations-kickbacks

49. Juarez G. Non-Profit Taxpayers Against Fraud Urges the Federal Court to Rule Against Stanford Hospital for $468 Million Alleged Healthcare Billing Fraud [Internet]. PR.com. [cited 2021 Aug 9]. Available from: https://www.pr.com/press-release/838884

50. United States v. Stanford Healthcare Billing Department.  United States District Court, Northern District of California.  Case 17-CV-08726-DSF-AFM.

51. Pallone F. Text - H.R.3630 - 116th Congress (2019-2020): No Surprises Act [Internet]. 2019 [cited 2021 Aug 31]. Available from: https://www.congress.gov/bill/116th-congress/house-bill/3630/text

52. HHS Announces Rule to Protect Consumers from Surprise Medical Bills | CMS [Internet]. [cited 2021 Aug 31]. Available from: https://www.cms.gov/newsroom/press-releases/hhs-announces-rule-protect-consumers-surprise-medical-bills

53.  AMA summary of the interim final rule of the No Surprises Act [Internet]. American Medical Association. [cited 2021 Aug 31]. Available from: https://www.ama-assn.org/delivering-care/patient-support-advocacy/ama-summary-interim-final-rule-no-surprises-act

54. Adams R. UnitedHealthcare Guided Yale’s Groundbreaking Surprise Billing Study [Internet]. The Intercept. 2021 [cited 2021 Aug 15]. Available from: https://theintercept.com/2021/08/10/unitedhealthcare-yale-surprise-billing-study/

55. “Damning assessment” finds few ties between physicians’ MIPS scores and stronger surgical outcomes [Internet]. FierceHealthcare. [cited 2021 Aug 9]. Available from: https://www.fiercehealthcare.com/practices/damning-assessment-finds-few-ties-between-physicians-mips-scores-and-stronger-surgical

56. Glance LG, Thirukumaran CP, Feng C, Lustik SJ, Dick AW. Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program. JAMA Network Open. 2021 Aug 3;4(8):e2118449–e2118449.

57. Kliff S, Katz J, Taylor R. Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why. The New York Times [Internet]. 2021 Aug 22 [cited 2021 Aug 25]; Available from: https://www.nytimes.com/interactive/2021/08/22/upshot/hospital-prices.html

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