Category: Podcast

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Highlights of this episode include:

• What is the Occupational Mix Survey
• When the survey is due
• Which hospitals must complete the survey
• What tools will providers need to complete the occupational mix survey
• Best practices
• Common missteps or issues

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome back reimbursement manager, Cody Bales. In this episode, Cody will provide us with a glimpse into BESLER’s next free Webinar, Occupational Mix Survey: Preparing for the CY 2025 Cycle that we’re hosting live on Wednesday, February 18, at 1 PM Eastern Time. Welcome back and thank you for joining us, Cody.

Cody Bales: Thanks for having me on, Kelly.

Kelly: Well, let’s go ahead and jump in. So, what is the Occupational Mix Survey and why is it important?

Cody: Well, the Occupational Mix Survey is a form that CMS requires providers to complete every three years. The survey requires reporting of salaries and hours primarily for the nursing staff, broken down into different categories. RNs, LPNs, and surge techs, nursing assistants and orderlies, and medical assistance. The current ACMX cycle will require wage data specifically from calendar year 2025. So, CMS then takes the data from the survey and calculates an overall nursing cost based on the dollars and hours for each nursing category. This basically is a blended average hourly rate for the nursing staff that is then compared to the national nursing average hourly rate.

And from there, CMS develops what’s called the occupational mix factor, which is a value that can be greater or less than one. This factor will then come in as a positive or a negative adjustment to the provider’s existing wage index data. And since, as I mentioned, the survey is only completed once every three years, once this factor is in place, it remains there for three years until the next cycle. So, the ACMX factor is incredibly important, and it really has the potential to greatly impact the hospital’s final wage index, which as we know is a major, major component of the overall payments that hospitals get from Medicare.

Kelly: So, when is the survey due?

Cody: Well, as we’re speaking today, CMS has not officially announced the due date for the calendar year 2025 survey. But traditionally, the ACMX timeline has been very consistent. So, we’re kind of pretty confidently anticipating that the survey will be due around June 30th of this year. That being said, due to the complexity involved in obtaining accurate data for the survey, providers should really be working on the survey now or sometime soon.

Kelly: Yeah, it sounds like it. That’s going to be here before we know it. So which hospitals must complete the survey?

Cody: The survey is required for essentially all IPPS hospitals. So that would, of course, exclude your critical access hospitals and other non-hospital types of providers.

Kelly: Okay, makes sense. So, what tools will providers need to complete the occupational mix survey?

Cody: The main data source is, of course, going to be a payroll report for your calendar year 2025. This will need to include dollars, and hours, and importantly job description or job title for all employees in the organization, not just the nursing staff. The report will also need to include departments or cost centers, which will impact where or if certain amounts are reported on the OccMix survey. So, providers will need to be able to map those departments in the same way that they do for cost reporting and for from wage index. And then most importantly, probably the reimbursement team will really need to be able to understand the roles or job titles from that internal reporting and determine which, if any, category of nursing that particular job should fall into for reporting on the survey. So this will really require a fundamental understanding of job titles and responsibilities and how each role fits in with the nursing team and the organization.

Kelly: Wow. Sounds like a lot of work and sounds very complex. So, with that in mind, do you have any best practices you can share with providers completing the survey?

Cody: Sure. To start with, it’s essential after you run, and you have the payroll report that you reconcile that to general ledger salaries for the same time period, calendar year 25. That may seem a bit obvious, but it can get overlooked. This helps ensure that the payroll report that you have is a proper basis for the survey. Another is really just to plan ahead and allow plenty of time to understand and properly categorize job titles and employees. This can and probably will necessitate working with HR, payroll personnel, and likely even nursing department directors. So, with that number of people potentially involved, again, it’s a good practice to allow time for questions to get ironed out. I would also mention that the RN personnel in particular should be carefully reviewed when preparing the survey. An employee that has RN and their job title will not necessarily go straight into that bucket on the survey. As the regs outlined, for example, that RNs who function purely in an administrative role would instead be reported in the quote-unquote “other” category on the survey. Additionally, RNs that are advanced practice providers, so think nurse practitioners, certified nurse midwives, CRNAs. Those should also not be reported in the RN bucket on the survey, and instead be excluded. So, to reiterate, it’s essential to be really diligent in reviewing the RN staff in particular.

Kelly: Wow, well, thanks for sharing those best practices with us. We do love those here. So, are there any common missteps or issues that tend to come up?

Cody: Yeah, I can mention a few. One is to ensure that contract labor is being fully accounted for. Contract labor is part of the survey. So, preparers often will go directly to obtaining the activity for the contracted nursing staff, so the agency nurses and so on, while really sometimes neglecting the other non-nursing vendors as the underlying data can be more difficult to pin down. All contract labor should be reported. And depending on the provider’s blend of staffing, excluding that, that non-nursing labor, can actually have a detrimental effect. It’s also important to not overlook reclasses that might be necessary for the survey. This can especially be a problem for those providers out there with non-calendar year ends as you have to really sit down and consider all the salary reclassifications that are utilized for the Medicare cost report when it’s again potentially on a different time period. So again, the step there is to take those, apply those same reclassifications to the calendar year data for the OccMix survey. And the last one that I’ll mention is that if the facility has any excluded type units, which would include psych or rehab units, any non-reimbursables, then it’s important to properly calculate that overhead portion that’s going to be applicable to those areas and then exclude that piece from the survey. So that would be in keeping with the wage index methodology. It really isn’t entirely obvious from the survey itself that that step needs to be performed. And so, it sometimes gets missed.

Kelly: Well, thank you for sharing those with us. And thank you so much for joining us, Cody, and for giving us this sneak peek into BESLER’s upcoming Webinar, Occupational Mix Survey: Preparing for the CY 2025 Cycle that you’re presenting live on Wednesday, February 18, at 1 PM Eastern Time. And as a bonus, you can earn CPE. Thanks again, Cody.

Cody: Thanks, Kelly.

Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• The biggest challenges hospitals and practices are facing right now
• Practical first steps to take to run more efficiently without burning out
•  Creating a smoother, more compassionate patient journey
• Operational improvements that tend to make the biggest difference
• Principles to follow to ensure new systems/team structures stay fully aligned with HIPAA and patient confidentiality

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Timothy Boyle. Tim is the Director of Sales and Business Development at REVA Global Medical, where he leverages nearly a decade of healthcare experience to help hospitals, laboratories, and private practices enhance patient experiences while optimizing revenue performance. Throughout his career, Tim has been dedicated to building solutions that bridge operational efficiency with compassionate care, ensuring that every patient interaction contributes to both satisfaction and sustainability. His leadership in sales and business development has supported numerous organizations in adapting to the evolving demands of modern healthcare. Before beginning his career in healthcare, Tim was a professional hockey player, an experience that instilled in him the values of teamwork, discipline, and perseverance, qualities that continue to drive his success in the medical industry today.

In this episode, we’re discussing the future of medical operations, efficiency, empathy, and virtual teams. Welcome, and thank you for joining us, Tim.

Tim Boyle: Wow, Kelly, what an intro. Thank you so much for having me.

Kelly: We’re happy to have you. Let’s go ahead and jump in. So, you went from professional hockey to healthcare leadership. What mindset or discipline from your playing days most influences how you lead in this industry today?

Tim: Absolutely. That’s a great question. And coming from professional hockey, and really any professional sports, the two biggest things I would say would be being consistent and being coachable. So for me, those are the two things I brought from the hockey world to the business world, was just every day being consistent, trying to bring everything I can to the table and working from that nine to five as hard as I can, given those practices, everything I got, as well as being coachable where even though I am a director of sales here at REVA Global Medical, I need to be able to pivot and I need to take advice wherever I can. And I think everybody should, up to leadership all the way down to the front-end workers who are out in the field every day. So, for me, definitely the two biggest things would be being consistent and being coachable.

Kelly: No, that makes a lot of sense. And it is quite a transition, but it sounds like you’re bringing some great things with you. Healthcare is changing fast. From your perspective, what are the biggest challenges hospitals and practices are facing right now when it comes to operations and staffing?

Tim: Yeah, obviously it’s a case-by-case basis, right? Healthcare practice can stream from anywhere from a small private practice all the way to a big hospital healthcare system. So, it varies from practice to practice, but I would say the biggest thing would be cutting costs and increasing revenue. With the price of labor, with the price of overhead, with even the price of materials increasing, these practices are looking for any way they can to cut costs. And for us, obviously, what we do here at REVA Global with providing a virtual assistant, that will be able to cut down on the admin costs. So, you don’t have to pay that $76-80,000 a year, which the industry averages on those office admins; you can be paying $12 an hour. So that’s really why we kind of got into the practice. I can tell you a little story too, Kelly, if that’s okay.

Kelly: Yeah, of course.

Tim: Yeah, so I come from 1 of 13 kids. So…

Kelly: Oh my.

Tim: Yeah, a lot of children in my family. And my oldest sister, Jen, is actually a primary care provider. Her and her husband, Alan, own a practice down in the south of Boston, Massachusetts. So, what I was actually– I came from the reimbursement space, and I was talking with my sister just about her practice and everything that was going on. And she says across the board with not only her practices, but a lot of practices, they’re having a hard time not only bringing people in to be office admins or to cover workload, but they’re just having a tough time being able handle all the tasks that are in there that they have going on in their practice. And the reason is, is just because the price of that office admin has just gotten so expensive. And without that office admin, obviously, you have a tougher time scheduling appointments, you have a tougher time checking eligibility. And then obviously, at the end of the day, they would have a tougher time collecting on that revenue for the services that you render. So, after talking with her for a long time… I actually have a buddy, Bob, who is also a professional hockey player that owns REVA Global Medical. And I called him just trying to find out what they did over here. And it kind of aligned perfectly, where obviously, healthcare, like you said, it’s changing very fast. And we need to find ways to be pioneers. And here at REVA, I think Bob is a big pioneer because he can take that office admin work off your plate and let doctors worry about that clinical work instead of that clerical work. So, I know that was a long-winded answer, Kelly, but the personal story is what really, really made me understand how fast healthcare is actually changing.

Kelly: No, I mean, I love the story, Tim. And I mean, these really are challenging times, so that’s a very appropriate story. For practices that feel overwhelmed were stretched thin, what are some practical first steps they can take to run more efficiently without burning out their teams?

Tim: Well, kind of like the last question, Kelly, I would say that this is definitely a case-by-case basis for sure. So, what I would say is take a step back and look at your entire workflow. Take a step back and look at what’s falling through the cracks. Do we need to put someone on the front desk? Is it appointment scheduling? Is it the prior authorizations you’re missing out on? When they get there, are you having a tough time verifying insurance? Is there an AR backlog that you got to handle? Obviously, like I said at the beginning, we need to cut costs and increase revenue, but where are we missing out on revenue? So, my answer to this question would definitely be just take a step back, look at your workflow, and see where you really need to implement new processes.

Kelly: Yeah, I love those practical steps. Thanks for sharing those with us. Patient experience is really becoming more important than ever. What have you learned about creating a smoother, more compassionate patient journey?

Tim: Well, patient experience is everything, right? And patient retention comes solely from patient experience. And for us, and what I’ve learned from coming from the technology space now to being here at REVA Global Medical, is the more information gathered upfront or before the appointment is scheduled, the easier and the more delightful that patient experience is going to be. So, for me, it would just be making sure that you handle all those prior authorizations, that scheduling of the appointments, and even the eligibility/insurance verification checks upfront. Because then when they get to the hospital or private practice, they’re not waiting in a waiting room, having to sit there and kind of sour their experience right from the jump. And when all of these tasks are taken care of on the front end, a lot fewer of them seem to fall through the cracks. And obviously, with less of those falling through the cracks, the more revenue that practice is going to be able to gather.

Kelly: Definitely. And I really loved what you said about the delightful patient experience. That’s amazing. That’s what we all should strive for, right?

Tim: Exactly.

Kelly: Yeah. So, you’ve worked with a wide range of providers. What operational improvements tend to make the biggest difference, whether that’s saving time, improving workflow, or enhancing revenue performance?

Tim: Yeah, so going back to our question too, Kelly, about taking a step back and looking at your workflow. Doctors go to school for years and years so that they can handle the clinical tasks in a practice, where there are a lot of practices where these doctors, these nurses are having to handle the clerical tests. So, what I mean by that, the patient care, the building patient plan, expanding the practices, the treatments, the making the care decisions. Those are all those clinical tests, right? But documentation, navigating the EHR, coding, chasing down labs for different tests, the prior auth, those insurance verifications, all the way to that backend billing. That’s all the clerical tasks. So, for us, improving these– improving the patient experience, improving the workflow, and enhancing revenue would all come from making– or not making, but allowing doctors to solely focus on this clinical work, that patient care, and then delegating the tasks of the clerical work. Now, going back to our conversation about how expensive it is for labor law and obviously overhead now, practices are going to have to find ways to be different and try to pivot from these office admins. So, I would take a look back, see where you need to see where you need to pivot, see where you need to change, and then implement that help where you need that change.

Kelly: Yeah. It really does sound like it’s all about improving that patient experience, so that makes a lot of sense to me. Let’s kind of pivot a little bit to something else, but compliance and data security are major concerns in healthcare. What principles do you follow to ensure new systems or team structures stay fully aligned with HIPAA and patient confidentiality?

Tim: Yeah. Absolutely. So, coming from the technology space, obviously, I know– I know that HIPAA is the most important thing for these practices, and HIPAA compliance is everything for us as well. So, we will run audits. All of our VAs will work out of their homes themselves. So, they are working out of one-bedroom apartments or a one-bedroom house. They have their own office. And we run HIPAA audits on their computers on a monthly basis, as well as system checks. So, we do everything to make sure that we check all the boxes for HIPAA compliance, because obviously we know how important it is in this field.

Kelly: Definitely. We do a lot of HIPAA compliance training here as well.

Tim: Oh, it’s everything.

Kelly: Yeah. Exactly. You are passionate about building high-performing teams. What qualities do you look for? And how do you help healthcare leaders cultivate teams that perform well under pressure?

Tim: Well, pressure just comes with performance, right? Or I mean, I’m sorry. Pressure comes with persistence, I would say. So, if you’re not prepared for something, pressure is preparation. So, for me, as a professional athlete, and obviously everyone’s going to feel a little bit of pressure. There was a national football game on last night, a national championship football game on last night. Obviously, those guys are preparing for weeks and weeks and weeks for that moment, but they’re going to feel a little pressure. So, I’m not saying pressure shouldn’t be there. But if you prepare, if you prepare to the best of your ability, then that pressure will be much less. And it should just feel like another day for you. And obviously, in the healthcare field, we go through different months, we go through different quarters where they’re high pressure because we need revenue in the door, and we aren’t getting patients in. So, when I’m building a team, I look for someone who’s going to be prepared, one. You’re going to be consistent, you’re going to be prepared, you’re going to be coachable, and you’re going to have strong work ethic. That’s what you look for in a hockey player and an athlete. And honestly, when I’m building out teams, when you’re able to be coachable, and when you’re able to be consistent, and you come prepared, you can really teach someone how to be successful in the healthcare space. Obviously, they’re not going to be a doctor, but if they work hard, they can be able to help these practices by providing the correct information, the correct consulting that they need to just increase revenue and cut costs like we were talking about at the beginning.

Kelly: Yeah. No. I love that. You made a lot of really good points there. Well, thanks so much, Tim, for sharing your insights with us on the future of medical operations, efficiency, empathy, and virtual teams. Really appreciate it. And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Tim: Absolutely. We are online. We have revaglobalmedical.com, but we’re also on Instagram, TikTok, Facebook, Riva Global Medical. We’re also on LinkedIn. But if you want to reach out to me personally, I’m also on LinkedIn, Timothy Boyle. And if you want to reach out just to have a conversation, I’m all ears, but that’s where you can find me.

Kelly: Great. Thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• What the webinar is covering
• Why it is an important topic to cover
• What is a spinal fusion
• Pitfalls in spinal fusion coding
• Documentation’s role in coding accuracy
• What difficulties coders typically face when coding these procedures
• Joint replacement coding
• Actionable tips

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome back Kristen Eglintine, BESLER’s senior manager of revenue integrity services of coding and projects. In this episode, Kristen will provide us with a glimpse into BESLER’s next free Webinar, Advanced Specialty Orthopedic Coding Tips: Spinal Fusions & Joint Replacements, that we’re hosting live on Wednesday, February 4, at 1 PM Eastern Time. Welcome back and thank you for joining us, Kristen.

Kristen Eglintine: Hi, Kelly. Well, and thank you for having me back. I’ve got some good information to share today, so I’m excited to be here.

Kelly: Awesome. Let’s go ahead and jump in then. So BESLER’s upcoming webinar, Advanced Specialty Orthopedic Coding Tips: Spinal Fusions & Joint Replacements, offers an in-depth look at ICD-10 PCS Coding for these complex procedures. Why is this an important topic to cover?

Kristen: So great question. Way to start it off. So orthopedic coding is a top priority for BESLER this year as it was actually driven by listener feedback. Coders and CDI specialists from our recent past webinars asked for more focused orthopedic procedure training. And that’s always something we look to prioritize. Why the strong interest in orthopedics, though? I’d say one of the reasons orthopedics is so engaging is that it really checks all the boxes. Complex anatomy. It has big financial impacts and outcomes that you can clearly see in the patients’ lives. So, when you’re working and coding cases like joint replacements or spinal fusions, it just doesn’t feel routine. It can feel significant and rewarding. There’s also clinical and human impacts. Orthopedic cases often restore mobility and independence. So, coders feel more closely connected to meaningful patient outcomes, whether that just be someone being able to walk again or just experiencing some pain relief. There’s also an intellectual challenge as orthopedics requires strong understanding of detailed anatomy. Orthopedic cases have a financial and compliance impact. Procedures are high-cost, high-volume, and heavily scrutinized, so accurate coding has a big impact on revenue integrity. So, when you put all of that together, it’s a topic that’s well worth exploring in more depth.

Kelly: Yeah. I mean, it sounds intriguing. You know Let’s dive right in with spinal fusions. What exactly is a spinal fusion? And why might a patient need one?

Kristen: Spinal fusion is a surgery that permanently joins two or more vertebrae so that they heal into a single solid bone and no longer move independently. The most common conditions treated with spinal fusions are those that would cause instability, deformities, or ongoing nerve compression, especially when conservative treatments just haven’t worked. In many cases, patients have already tried options like PT, they’ve tried medication or injections without lasting relief. These situations often stem from degenerative changes in the spine. They can stem from traumatic injuries or underlying structural abnormalities. And then over time, these issues lead to pain, loss of function, or neurological symptoms that significantly impact a patient’s quality of life. So, when that happens, a spinal fusion becomes a way to stabilize the spine. It reduces abnormal movement and relieves pressure on the nerves. Coding a spinal fusion is tricky. The code set expects precise detail on anatomy, levels, approach, techniques, and devices. And all of that has to be pulled correctly from the operative note. So then even small misreads can lead to the wrong code, the wrong number of levels, or just missed add-on codes.

Kelly: Can you expand on that last thought? What does a coder need to pay special attention to in an operative note to code a spinal fusion correctly?

Kristen: So great question. Spinal anatomy is complicated, and that’s where a lot of the coding challenges come in. Coders have to clearly understand the difference between vertebral segments versus inner spaces. They have to know how to correctly count levels and recognize when a fusion crosses regions like cervical into thoracic or lumbar. On top of that, there are multiple surgical approaches and techniques. A surgeon might use an anterior, posterior, lateral, or even a combined approach in the same case. And each of those maps to different codes. Depending on which vertebrae are being fused, the patient’s position could vary. Sometimes they’re prone while the surgeon accesses the spine from the back, and other times they’re supine, and the surgeon is working through the neck. Coders also need to pay attention to the devices used, whether that’s cages, interbody fusion devices, or instrumentation versus simple fixation hardware, and make sure the bone graft types and sources are captured accurately.

Kelly: Very interesting. It sounds very intricate and complex. Could you highlight the most common pitfalls in spinal fusion coding?

Kristen: Yeah, there definitely are some. A few coding challenges that we will really try to address in the webinar are– the first one I’d say is around device selection. Expanding on what I just mentioned, coders sometimes confuse the internal fixation hardware, like plates and screws with the true fusion device, such as the interbody fusion device, a cage, or the bone graft itself. That distinction matters in ICD-10-PCS, and it’s not always obvious in the operative note. Another big pitfall has to do with coexisting procedures performed during a spinal fusion. So, fusions are often done alongside a laminectomy or a diskectomy or an osteotomy or deformity corrections. And coders have to know which of these services are considered part of the fusion and which ones can be reported separately. And again, this is not always a clear line. One reason it’s so challenging is that multiple procedures often happen in the same anatomical region. When several spine procedures take place at the same operative site, coders have to carefully interpret the operative note to understand exactly what was done, why it was done, and whether it meets the definition of a separate PCS route operation. Another challenge is that some procedures are actually inherent to the fusion itself. So, for example, let’s look at decompressive work.

So that may simply be part of the surgical exposure needed to complete the fusion, or in other cases, that decompression is a separate, clinically necessary service. And knowing the difference requires close reading and a solid understanding of PCS definitions. And then there’s the surgical approach. So, the approach used to reach the vertebrae, again, so whether that’s anterior or posterior or lateral or combined, it can be tricky to identify and does have a direct impact on the code selection. That means coders really have to slow down and carefully read the operative note to make sure they’re interpreting it correctly.

Kelly: Wow, thank you for sharing those pitfalls with us. We emphasize documentation’s role in coding accuracy in many of our webinars. Would you say that’s especially true for spinal fusions as well?

Kristen: Absolutely. Documentation variability is another big challenge. Surgeons don’t all describe levels, approaches, and devices the same way. So, coders have to translate that narrative language the surgeon would use into very specific code terms. And when those details aren’t clearly there or documented, clarification becomes critical, such as a query. Otherwise, you’re risking denials, audits, or just inaccurate data.

Kelly: So let’s go ahead and turn into joint replacements. What difficulties do coders typically face when coding these procedures?

Kristen: So joint replacement coding can be tricky, just as spinal fusions, because there are so many code options, a lot of documentation detail to capture, and even small mistakes here can have a big financial impact too. Hip and knee arthroplasties in particular come with dozens of possible ICD-10 PCS codes and related billing combinations. So, translating the operative no into the most accurate set of codes isn’t always straightforward. Let me give you a few examples of the level of detail coders really have to capture when it comes to joint replacements, because this is where it can get tricky.

So, first, there’s the anatomic and procedural detail. Coders need to know the exact side, so right or left. They need to know the specific joint involved. So, it could be hip, it could be a knee, sometimes even a shoulder. And whether the procedure was partial or total or a revision, every one of those details changes the code. Revision surgeries add another layer of complexity. That documentation has to be clearly spelled out, including which components were removed, which were left in place, and which were replaced. So, things like the femoral or tibial component, the liner, or the patella, different combinations of those actions can point to entirely different codes. And then on top of that, there’s a lot of code choices that sound very similar.

So, in ICD-10 PCS, a joint replacement can translate into hundreds of possible options based on body part, approach, device, and material. That really increases the risk of inconsistency or miscoding if the documentation isn’t crystal clear. For revisions in particular, coders are often deciding between codes that seem almost interchangeable, like removal, replacement, or revision of a synthetic substitute. But, really, each represents a distinct root operation. Understanding those subtle differences is critical because it directly affects the PCS code and how the procedure is ultimately reported.

Kelly: Wow, so it seems joint replacement coding is every bit as challenging as spinal fusion coding. Can you tell us a little bit more?

Kristen: Oh, yes, it definitely is every bit as challenging. When it comes to total hip and knee replacements, the documentation really matters. Coders need clear details on laterality and the joint involved. Again, right versus left, hip versus knee, and then whether it’s total or partial they also need to know the type of material of the prosthetic. So, whether it’s cemented or uncemented, they need to know whether it’s metal or ceramic and whether it is an initial replacement or a subsequent procedure. Another big distinction is whether the surgery is a true replacement or a revision in ICD-10 PCS. So, a revision usually means adjusting or correcting part of an existing prosthesis, like swapping out a liner or repositioning a component. A replacement, on the other hand, involves removing the old prosthesis and putting a new one in. And that distinction drives the root operation and ultimately, again, affects what code we report.

Kelly: Thank you for explaining that for us a little bit more. So, if listeners want to walk away with just one actionable tip from our conversation today, what should it be?

Kristen: If there’s one takeaway from today’s discussion, it’s this. Solid, precise documentation is the foundation of accurate and compliant orthopedic coding. Whether you’re coding a spinal fusion or a joint replacement, the level of detail in the operative note. So, anatomy, approach, devices, levels, and intent directly determines coding accuracy. It directly determines reimbursement integrity and your audit risk. Clear documentation empowers coders to choose the correct route operations, capture all clinically significant procedures, and avoid denials or data errors. And that’s exactly why training, like our upcoming webinar, is so valuable. So, I highly recommend please take an hour. Join us Wednesday, February 4, 1 PM Eastern Standard Time. I promise you won’t regret it. Thanks again for listening and being part of our audience today.

Kelly: Thank you so much for joining us, Kristen, and for giving us this sneak peek into BESLER’s upcoming webinar, Advanced Specialty Orthopedic Coding Tips: Spinal Fusions & Joint Replacements, that you’re presenting live on Wednesday, February 4, at 1 PM Eastern time. And as a bonus, you can earn CEU. Thanks again, Kristen.

Kristen: Thank you. Have a great day, everybody.

Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• How Glass Raven started
• Connecting patient access directly to the bottom line
• How data-driven staffing models can improve revenue capture/reduce leakage
• How right-sizing staffing led to measurable financial improvement
• Where hospitals are leaving the most money on the table
• How finance and operations leaders can partner more effectively
• First steps hospitals can take to use its existing data more strategically

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Peyton Fry. Labor is a hospital’s largest expense and one of its biggest opportunities for financial improvement. In this episode, Peyton, founder of Glass Raven, explains how leading hospitals are using data science and staffing analytics to improve patient access, reduce leakage, and boost revenue capture. Discover how hospitals can make better workforce planning decisions using analytics that link operations directly to financial performance. Welcome, and thank you for joining us, Peyton.

Peyton Fry: Yeah, thanks, Kelly. Happy to be here.

Kelly: We’re glad to have you. Well, let’s go ahead and jump in. So, Peyton, can you tell us how Glass Raven started and what problem in healthcare operations you set out to solve?

Peyton: Yeah, so Glass Raven was founded to– really what it boils down to is moving the needle meaningfully in patient access spaces for hospitals, healthcare systems, and outpatient groups. And it kind of emerged from my early days as a data analyst working for a healthcare system, working with ACOs, central scheduling, call centers, really just broadly working in operation spaces centered on patient access. And I think I didn’t really understand why I was successful as an analyst until I started going out on my own and having to sell myself as this consulting group, and discovering that even though our biggest tool set and kind of what we bring to the table for organizations is advanced data analytics, really, I think the value is in how it gets applied and adopted by an organization to not just automate some steps, remove some reporting problems, but really, really change the culture of an organization to really having executives down to line-level employees centered around the metrics we’re trying to move and understanding the decisions that they can individually make to really improve those pieces week over week. Because I think without that kind of vertical integration, you really don’t adopt a process. I think you just kind of talk about it.

Kelly: Well, thank you for sharing that about Glass Raven and your experience there. Many hospital finance teams don’t always connect patient access directly to the bottom line. Can you explain that connection?

Peyton: Yeah, so the connection between patient access and finance, I think, is normally talked about in a healthcare system once a year around budget cycles whether that be April or November for your team. Typically, when we work with organizations, we’re working with the operational group and how they’re going to change processes. And we talk about finance when it becomes pertinent for how are we going to incorporate new additions or programs or staffing into a budget cycle. So, I think a lot of the problem is that finance and operations don’t really talk to each other around patient access unless budgets involved. A lot of this is, I think, because there is really, really poor benchmarking availability for operational groups to kind of point to and say, “This is what our peers are doing,” or, “This is what we should be doing instead,” which makes it difficult, I think, for finance teams to decide whether to apply capital to a situation, whether to pull capital away into different directions. And patient access kind of has a– it’s a known paradox, but it’s hard to put a finger on it, which is we know that without patient access, we don’t see patients. But it’s hard to say how much money are we spending to get some sort of a return. And this is because, I think, between different organizations, you’ve got different payer mixes. Some people are trying to bring in revenue through commercial groups, and some groups are trying to manage costs for their capitated populations. So, I think it’s really difficult that I think you almost have to reinvent the wheel for every healthcare system based off your operations mix and your payer mix, to really have meaningful conversations between those two groups.

Kelly: Yeah, that makes a lot of sense. There’s a lot of moving parts there. How can data-driven staffing models or access analytics improve revenue capture or reduce leakage?

Peyton: Yeah, so having a strong data-driven process really comes down to how are you looking at staff productivity? Especially with referral management groups is where you’re going to really focus on capturing revenue from those high dollar specialties, or reducing patients from leaking out of your system to your competitors or local groups, because they just can’t get in contact with you, or they can’t find an appointment that works for them. So, making sure that you have strong trained agents on that referral team that know how to get the right patient to the right place at the right time, and then mapping that to a provider network that has capacity for those appointments that you’re trying to schedule for. So, you really need to look at it from both sides. You could have the best central scheduling referral management group in the world, but if you don’t have any provider capacity left, there’s nowhere to put them. It’s no longer worth spending money on your call center. You should be focusing on hiring more providers if you’re really trying to capture those commercial patients. On the flip side, if you’re trying to really control your managed population, if you’re doing Medicare Advantage or you’ve got an HMO, making sure that you get people into their appointments quickly to check off their measures, reach compliance with whatever government programs you’re participating in, making sure that it’s probably not necessarily capturing revenue for you, but it is protecting your margins because you are going to check all those boxes and get the maximum reimbursement you can for those groups.

Kelly: Well, thank you for sharing that with us. Can you share an example where right-sizing staffing led to measurable financial improvement?

Peyton: Yeah. For Glass Raven, our bread and butter normally is working with call center groups and central scheduling because it’s don’t have to worry so much about HIPAA compliance or getting into EHR data work, but it’s a space that a lot of healthcare professionals don’t like to work. So, there’s not a lot of expertise that sits in those spaces. It’s just a special place that’s near and dear to my heart. And working with groups and kind of getting them up to kind of industry standard basics for a call center really helps with staffing models. And focusing on the right metrics, abandonment rate, service level, and throwing out a lot of noisy metrics that are all related to those pieces can really help people focus and dial in what they truly need to handle a central scheduling call volume. And we work with groups and swiftly over like a period of six months to a year saw FTE reductions of like 40 to 50, numbers that even I wasn’t expecting going into it. But it was just having people at the wrong place at the wrong time, changing schedules around, and showing like, “We can do more with the same,” or, “We can do more in a lot of cases with less.” And so doing better staffing on call centers is often an easy place for healthcare systems that haven’t given it a lot of attention to optimize that workforce and get a lot of those dollars back.

Kelly: I love what you said about noisy analytics. That was a really good call out and I love the example. In your experience, Peyton, where are hospitals leaving the most money on the table when it comes to patient access?

Peyton: I think where a lot of the money gets left on the table is not understanding what dials they’re trying to move left, right, because often they just don’t have a lot of metrics to focus on. And so, they end up kind of doing whatever’s shiny. I think it’s really easy– in patient access spaces, I don’t know if it really necessarily looks like money left on the table because patient access by itself isn’t what’s creating your dollar revenues. Unless you’re seeing a provider, you’re not creating money as a healthcare system. You’re not getting reimbursed by the programs you participate in. So, I think a lot of the money is in cost control in patient access spaces that result in clinical work that gets done. So, I think focusing on kind of shiny technologies that maybe aren’t attached to a return on investment on the finance side, can lead to vendor agreements that don’t solve problems. They might look shiny, they might have AI in there and sound agentic, but they don’t necessarily result in more provider visits or more efficient provider visits because that’s really what you’re trying to get down to for revenue. So, I think there’s a lot of interplay with vendors and technology that don’t create returns. And again, it kind of goes back to the question you asked earlier is finance and operations, talk about it more than once a year and figure out on the revenue capture side and the cost control side for our populations, are the changes we’re making in patient access moving those needles in a way that we can track?

Kelly: Definitely. I mean, I love what you were saying about the new shiny technology and tools. I know so often we do get caught up in that and I completely agree with you. We were kind of heading with that. You talked about this a little bit. How can finance and operations leaders partner more effectively to make these improvements stick? And like I said, you did mention this, so I’d love to hear more about this.

Peyton: Yeah, so I think the way you make an improvement stick– I’ll probably answer this in two parts. There’s improvement sticking and there’s finance and operations leaders working together. When it comes to getting an improvement to stick, I think a great example is probably everyone that’s listening to this podcast has had an organizational venture on we’re going to totally revamp and send everyone to training for something like Six Sigma or Lean or we’re going to do a Myers-Briggs personality test and talk about how we do communication. And you do it, the training is exciting for like three, four weeks, and then it kind of fades. And it’s never mentioned again. Six Sigma doesn’t really take root because it’s really hard to kind of be accountable to it because there’s not a way– we didn’t measure going into it, how Six Sigma was going to move the needle. Therefore, we didn’t know how to apply it meaningfully later to get returns on the investment of these programs. And that’s a broad example that probably everyone’s experienced, but I think this is where people get in trouble when they engage with vendors and they don’t know what needle they were trying to move in the first place meaningfully. I think part of that is also there’s a lack of accountability by the vendor or the service group or the consultant around being transparent around what they expected to change and then what they changed at the end.

So, making sure that we have something that we’re going to agree on early and then we’re going to follow it from the executive level down to the people that have the day-to-day process changes, those agents, providers, front desk staff, making sure that they’re all talking about the same thing. We’re not just going to send our executives to training. We’re going to make sure that everyone, top to bottom, understands what service level is, understands what abandonment is, and then mapping that to the decisions that they can make. And then seeing that change week over week and talking about it. So, kind of having a vertical way to talk about a change that we’re trying to make and then watching it longitudinally and watching it weekly, especially early on. And ultimately, it becomes something you look at less and less because it sticks. But that’s where I would start there. Popping back to the first part of the question, how do finance and operations leaders partner more effectively. It’s kind of the same thing that we just talked about, but horizontally. Let’s agree upon a metric that’s important and that we’re both accountable for. And we both understands what decisions that we can make. Finance understands that this is our jurisdiction, operations. This is our jurisdiction. And then talking about the data and the kind of the turning points on when they’ll make different decisions one way or the other. If you don’t understand what decisions your partners can make and how they impact your operation or your day-to-day, you’re not going to talk to them. And you’re going to talk to them once a year when it’s mission critical and the house is on fire.

Kelly: Right. No, I mean, I love what you were pulling out, the accountability and the transparency between the groups. That makes a lot of sense. So, what are some first steps hospitals can take to use its existing data more strategically for access optimization?

Peyton: First steps I would say are take a look at all of your dashboards and decide if that dashboard ceased to exist. If I no longer had access to this data point or this metric, does anything in my day-to-day change? Does anything in my week-to-week, month-to-month change? If the answer is no, you have a fun fact dashboard that you should get rid of. And I think a lot of it comes down to hospitals have an overwhelming amount of data availability. EHRs are built to manage data clinically. I think I’m going to say I haven’t seen an EHR where I’ve been happy with the way that their business analytics is set up out of the box. This is where hospitals kind of have to invent it themselves. And they are handed a lot of stuff that they’re told is the tool of the trade, but it doesn’t apply to their problems. Leaders oftentimes, they have fun fact dashboards and then they just start making decisions based off their gut because leaders do know what’s important to them in their organization and they do know how to move the needle. But they end up having to kind of do it as a gut reaction, which makes it really hard to sell change because you can’t convince your peers of the same thing. So taking a look at what data is important to us really, what do we use to make decisions and just starting to strip out the rest so that you can focus on only what you’re actually going to use to make decisions and kind of identify these are the areas where we’re making our decisions off our gut and we do need data-driven decision ways to make this.

Kelly: Right, no, I love that. I mean, I think that a lot of us make decisions from our gut, but we kind of do need that data to back it up. Well, thank you, Peyton, for sharing your insights with us from wait times to revenue wins, how operational analytics are transforming patient access. If a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Peyton: Yeah, so easy way to find me is on LinkedIn. I’m at my desk most of the time working with data one way or the other, so I’ll get those notifications quickly. You can also reach out to us over our website. That’s at glassraven.health, spelled just like it sounds. You can check out kind of some of our past projects, how we do work, what we do for partnerships, easy way to find us there as well.

Kelly: Awesome. Thanks for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• What the webinar is about
• Target audience for this webinar
• Topics that will be covered
• Disproportionate share adjustment
• Supplemental payments

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome back Christina Brown, BESLER’s Vice President of Reimbursement Services. In this episode, Christina will provide us with a glimpse into BESLER’s next free Webinar, Uncompensated Care Series – Overview, that we’re hosting live on Wednesday, January 21, at 1 PM Eastern Time. Welcome back and thanks for joining us, Christina.

Christina Brown: Thanks so much, Kelly. It’s always a pleasure.

Kelly: Yes, it is. So, let’s go ahead and jump in. So, we’ve seen a number of webinars on this topic. Can you give us a little bit of insight as to what this webinar is all about?

Christina: Sure thing. Yeah, that’s a true statement. So uncompensated care is a pretty hot topic when it comes to reimbursement. It makes sense that there’s a ton of interest and coverage on this particular topic. And we do like to discuss this one regularly as there are new people that enter the reimbursement profession. And that’s just really due to leading industry experts that are exiting the workforce. I think a lot of areas are saying that. It’s also imperative to cover this topic as this area has really evolved over recent years. But basically, uncompensated care is defined by CMS as care that is provided for which no payment is received or expected to be received from a patient or insurer. Specifically, what I’m referring to is really bad debt and charity care. However, uncompensated care also relates to another area worth mentioning, and that is the effect that it has on Disproportionate Share Hospital payments as the DSH hospitals have a high volume of Medicaid patients in proportion to total payer volume.

And if you’re aware, that’s really because Medicaid has a lower reimbursement rate than other payers do. So now I’m going to cover this relationship for those who may not understand that connection. And while I will touch on the basics of uncompensated care, things like where it’s reported on the cost report and how the payments work, I will save the deep dive into processing specifics for other webinars in the series.

Kelly: Right. Yeah. I know this is always a very popular topic. So, who do you feel would be the target audience of this webinar?

Christina: Yeah. And that’s a great question, and I’m happy to address that. So, I believe this webinar would be great for those that are new to reimbursement or may not fully understand uncompensated care. I’m going to provide some general terms used when discussing uncompensated care as well as some basic need-to-know items to understand its impact. And in addition to reimbursement professionals, I also feel this would also be a good webinar for those that may not need to know all of the details of uncompensated care and goes into preparing it for the cost report, but perhaps would like to have some basic knowledge on the topic.

Kelly: Awesome. Yeah. I know there’s a lot of people who would benefit from this. And we’ve discussed that we’ve done a few webinars on this topic, you and the team around the topic of uncompensated care. Can you go into a little bit more detail as to some of the topics that you’re going to be covering?

Christina: Yeah. And you’re absolutely right again. So, we do touch on this topic in a variety of ways due to its complexity, importance, and reimbursement. So, there is really so much to cover on this topic. So, we really want to ensure that we address this often in order to cover any updates as well as present it in a multitude of ways in hopes that information will connect with our attendees. That being said, for the basis of this webinar, it will be more broad than the ones that we’ve done in the past. So, for example, we have done specifically ones related disproportionate share, where we talked about how it’s related to uncompensated care. Then we went more in depth on how hospitals qualify for DSH and how to process the data needed for the cost report. We’ve also done webinars where we went in depth on Worksheet S-10, which is where the uncompensated care is reported. This webinar, as I mentioned, is going to be more broad in content and really less specific on the granular details of processing the data for the cost report.

However, no need to worry. We will get into those specifics with other ones in the series as we want to ensure we cover any new developments since our last webinars on this topic as we have seen some evolution in the S-10 audits as well as some legislative updates impacting DSH.

Kelly: I mean, things are definitely always changing, that’s for sure. You mentioned the disproportionate share adjustment. Will you be going into any detail around those payments and how to process the data?

Christina: Yeah. So unfortunately, I would need a lot more than the allotted hour to cover the basics as well as all the processing data elements necessary to file the cost report. So, for this one, I’m really just, as I said, touch on the basics of the Disproportionate Share Hospital adjustment and its relationship to uncompensated care, and how what’s filed on the cost report for uncompensated care on Worksheet S-10 impacts payments for hospitals that are eligible for that Disproportionate Share Hospital adjustment payment.

Kelly: Great. Looking forward to that. So, since you’re going to be talking about uncompensated care and how it relates to the supplemental payments, will you also be spending time talking about Worksheet S-10?

Christina: Sure. So yeah, that’s another great question, Kelly. So, if you know anything about uncompensated care and cost reporting, you probably already know and understand the importance of the exhibits that must be filed with the Medicare cost report. However, as with DSH, there’s simply not enough time in the allotted hour or with this webinar to go into all of the processing and data elements for the exhibits. So that’s really why we made this a series. So later, we do plan to do a deeper dive into Worksheet S-10 as well as the Disproportionate Share Hospital or DSH. And for purposes of this webinar, I am really going to only touch on the exhibits, and we’ll not go into any detail on all the various data components and how to process it and all those things. But I do encourage you to stay tuned for our other webinars in this series that will provide that level of detail. But that’s not to say to skip on this one, as you will obtain not only the CPE credit early in the year, but perhaps hopefully gain some additional insight on uncompensated care.

Kelly: Yeah. It’s sure to be a great webinar as well as the future ones we’re going to have this year. Well, thank you so much for joining us, Christina, and for giving us this sneak peek into BESLER’s upcoming webinar, Uncompensated Care Series – Overview, that you’re presenting live on Wednesday, January 21, at 1 PM Eastern Time. And as a bonus, you can earn CPE. Thanks again, Christina.

Christina: Thank you so much, Kelly.

Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• Current challenges impacting prior authorization workflows today
• What impact data quality has on prior authorization
• How the CMS Interoperability and Prior Authorization Final Rule will impact how teams exchange and structure data
• How data quality impacts a hospital’s bottom line

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome Shobha Phansalkar, PhD, FAMIA. Shobha is the Vice President of Client Solutions and Innovation for Wolters Kluwer Health Language, where she leverages her extensive expertise in medical informatics to drive impactful solutions that address challenges in semantic interoperability and enhance healthcare data quality. Shobha has been in the healthcare information technology field in industry and academia for more than 20 years. She is an internationally recognized thought leader in the field of clinical decision support and a fellow of the American Medical Informatics Association. In addition to her roles in the industry, she has published more than 50 peer-reviewed articles and book chapters on CDS and led research for the Agency for Healthcare Research and Quality, the U.S. Department of Veterans Affairs, and the Office of the National Coordinator for HIT. She also serves on the editorial board of BMC Informatics and Decision Making. Welcome, and thank you so much for joining us, Shobha.

Shobha Phansalkar: Thanks, Kelly. Pleasure to be here.

Kelly: Great. Well, let’s go ahead and jump in. So, Shobha, please tell us about yourself and your background.

Shobha: For sure. First, thank you for the opportunity, Kelly. Appreciate that. Thank you for that introduction as well. A bit more context on who I am and Health Language, which is a part of Wolters Kluwer Health. So, I’m a clinical informaticist and a pharmacist by background. Over 20 years in the healthcare IT space. I lead Client Solutions and Innovation at Health Language and our customers span the healthcare ecosystem, where we serve payers, providers, life sciences with the ability to improve data quality. And that really is the foundation of the value proposition that we provide our customers with, where we serve as a single source of truth for industry standards, your reference terminologies, but also help them improve the quality of their data by standardizing and normalizing it.

In addition, we serve as the providers of knowledge assets, code groups, value sets that help them power their business rules, as well as their clinical decision support processes.

Kelly: Wonderful. Thank you for sharing that with us. So, Shobha, what are the current challenges impacting prior authorization workflows today?

Shobha: Oh, huge ramifications. And a key time for us to be talking about this. As you know, prior authorization has been front and center in the news this year. It’s unfortunate from many perspectives. But I think because your audience is hospital finance focused, it might make sense for me to share some staggering numbers associated with prior authorization. So just to give you a sense of the magnitude of the problem, right? $11 billion, that’s billion with a B, is spent by providers in prior authorization transactions, purely from an administrative perspective. And if you think about it, that’s time taken away from clinical care. Now, 37% of these transactions are manual, and the cost per transaction is at an average of about $11.

If we were to make that transaction electronic, it actually halves the amount spent, which is at about $5.70. Now, the kicker here is that irrespective of whether it’s a manual or an electronic transaction, a large part of the burden of that cost is taken up by providers. About 70% of that cost is taken up by providers and about 30% by payers. That’s a huge burden on providers. And granted the numbers are large, but the impact that that has in terms of provider burden, a recent survey by the American Medical Association actually showed that 88% of providers felt that PA requirements posed a high or extremely high burden on them. And if you take that thread and think about what that means to patient care, 30% of them said they didn’t even think that the PA requirements were evidence-based. And another third thought that they might actually abandon the care of their patient because of the administrative overhead associated with prior authorization.

So, the reason I’m mentioning this, Kelly, is there is the financial or the cost aspect for it. But there’s also a huge burden that it poses on denied, delayed care for patients, as well as huge burden on providers resulting in provider burnout.

Kelly: Wow. Yeah, those are some significant challenges, Shobha. Thanks for sharing those with us. So, what impact does data quality have on prior authorization and ensuring patients receive coverage for appropriate care?

Shobha: Yeah, great question. I mean, there’s so much that we see in the news about the frustration that members and patients have when they have to deal with prior authorization denials or just the burden of going through the process of requesting prior authorization. But if you think about it, a study shows 30% of these requests get denied. 40% of those are actually related to poor data quality. And that’s where the opportunity is. I mean, I think with all of the huge numbers that we have come to recognize, I think it’s important to recognize where can we make a difference. I think the difference is in making these electronic, in standardizing the data that’s being shared between payers and providers, as well as making sure that the data is of high quality so that patients are able to get their requests approved or receive a reason for what the next step is quickly.

That’s going to fundamentally be made possible by having good data quality that’s exchanged between these systems and making sure that there’s interoperability within that data exchange. What that means, Kelly, is that fundamentally when two systems are talking to each other, they need to use the same language. And a lot of the regulations that are coming through are actually focusing on that. They’re making sure that not only are we exchanging the data in standardized FHIR APIs, but we’re making sure that we call out the terminologies that will populate these FHIR APIs. And that standardization rings right home to what we do at Health Language because we are making sure that we can take that data, we can serve it up as good quality data, not just from validating the terminologies that are used for this data exchange, but also making sure that we are supporting our payer customers in being able to represent that data as high quality data that can then reduce the amount of time for prior authorization requests.

Kelly: Wow. I mean, thank you so much for sharing that. That’s quite the significant impact. So how will the CMS Interoperability and Prior Authorization Final Rule impact how teams exchange and structure data?

Shobha: Yeah. No. Like I said earlier in this conversation, I think our conversation is so timely, right? A lot of good information as well as conversation has happened to support this prior authorization rule. The CMS Final Rule, which is 0057-F, basically mandates the use of FHIR-based APIs and produces transparency around prior authorization. And that’s fundamental, right? Because not only are you imposing deadlines for implementing the FHIR APIs, but you’re also calling for the decision timeframes to be expedited. You’re calling for transparency requirements so that both providers and patients are aware as to whether their request was denied for a certain reason and how they can ameliorate that. So, all of this, I think we’re in a very good place in terms of serving the needs of the problem, which is making sure that we are standardizing the exchange of information, but also accountability so that providers as well as payers can have expedited decision-making for this process.

Kelly: Most definitely. Thank you for sharing that. And how does data quality impact a hospital’s bottom line, especially around prior authorization?

Shobha: Yeah. That’s– it all comes down to making sure that we are making sound financial decisions. I mean, given the market and given that where we are economically as different parts of the healthcare system strive for better bottom lines, I mean, I think data quality directly impacts financial performance. So let me give you an example of that. Recently, we collaborated with MCG Health, a big player in the space of utilization management. And what we were able to show is by creating knowledge assets, which we call value sets in order to power their utilization management engine, they were able to bring down the average amount of time that a utilization management nurse spent in reviewing a request from 20 minutes to 3 minutes. Just think about that. That’s staggering, right?

Just by making sure that we are exchanging data in a standardized way, they were able to bring back the right information about that patient from the EHR, extract it, summarize it, present it back to the utilization management nurse, and that three minutes is 85% faster than the national average. So, think about everything we talked about in terms of the financial burden. That itself was reduced. A $42 million savings annually that MCG Health now has because it’s able to power their rules for decision-making better. And so I tie that back to your question, which is if we can standardize the way we are exchanging information between payers and providers, just like MCG Health example, we would be able to get better data between these entities, whether it’s the provider sending the prior authorization request and knowing at the point of care, “What are the documents or what is the information that I need to provide in order to make sure that I have a successful request submitted to the payer?” And also for the payer to then know, “What’s the documentation that I need in order to make sure that I’m providing the right decision back to the provider?”

So, all of this rings or resonates very closely to what we do at Health Language, and we are very excited for the Prior Authorization Final Rule because it aligns very much with what we consider as the data quality journey for our customers. There’s sort of that threefold impact. You’re making sure that the terminologies that are powering these fire APIs are containing valid codes. You’re making sure that the data quality that’s exchanged between the provider and the payer is good quality data. And then last but not the least is making sure that the rules or the benefits that the payers are sending back to their providers are represented as standard value sets that can then be used to make streamlined decisions on what that prior authorization request should be.

Kelly: Yeah. I mean, data quality is so very important, and I think you kind of proved it with what you just said. Well, thank you so much, Shobha, for sharing your insights with us on where data quality can make or break prior authorization accuracy. We appreciate all your insights.

And if a listener wants to learn more or contact you to discuss this topic further, how best can they do that?

Shobha: Oh, thank you for asking that, Kelly. We are always excited at Health Language to talk to people about what we do. Our website carries a wealth of information, our value proposition, and our offerings to the market. In addition, when you go on the website, you can see that there’s the option to speak to an expert. That’s another way that we can have a conversation. Would love to learn about where we can help.

Kelly: Great, thank you for providing that. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.holdings/podcasts. The Hospital Finance Podcast is a production of Besler Holdings.

Given the significant impact quick fixes in data quality infrastructure can have on an organization’s prior authorization infrastructure, Shobha and her team of informatics experts are happy to meet with any of our listeners to review your current data supply chain and evaluate quick wins to accelerate your path to compliance with the prior authorization rule. Schedule a meeting with her. 

Additional Resource: https://www.wolterskluwer.com/en/expert-insights/bridging-the-data-divide-between-payers-and-providers?utm_campaign=core-thought-leadership&utm_medium=referral&utm_source=beslers

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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Highlights of this episode include:

• Acumens on the outpatient updates for calendar year 2026
• Changes CMS has made to outpatient payment in the 2026 OPPS final rule
• 340B program updates
• The inpatient-only list

Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast.  We’re pleased to welcome back Bob McDowell, BESLER’s Senior Reimbursement Consultant. In this episode, Bob will provide us with a glimpse into BESLER’s next free Webinar, CY 2026 OPPS Final Rule Summary, that we’re hosting live on Wednesday, January 14^th, at 1 PM eastern time. Welcome back and thanks for joining us, Bob.

Bob McDowell: Well, thank you, Kelly. It’s a pleasure to be with you today.

Kelly: It’s a pleasure to have you on. Well, let’s go ahead and jump in. So, in the final rules, CMS updates the payment rates for covered services. Can you give us some acumens on the outpatient updates for calendar year 2026?

Bob: Absolutely. For calendar year 2026, outpatient payment rates for hospitals that meet the quality reporting requirements will increase 2.6%. This increase is based on the market basket increase of 3.3% and reduced by a 0.7% or 7/10 of a percent productivity adjustment. Once the budget neutrality factors are applied, we see the conversion factor increase from $89.17 for calendar year 2025 to $91.42 for calendar year 2026 for facilities that are not affected by the 340B remedy offset. For hospitals affected by the 340B remedy offset, they will see an increase to $90. 97. These conversion factor updates result in a net increases of 2.519% and 2.017% respectively. CMS estimates that the calendar year 2026 OPPS total payments to providers to be $101 billion, an increase of approximately $8 billion compared to estimated calendar year 2025 OPPS payments. CMS is continuing the policy for hospitals that do not meet the outpatient quality reporting requirements to experience a 2% reduction in payments using a reporting factor of 0.9805 applied to OPPS payments and copayments. CMS has extended the 7.1% adjustment for rural sole community hospitals and essential access community hospitals for calendar year 2026.

Kelly: Thank you for those updates, Bob. So, the wage index has received a lot of attention in recent years. Can you elaborate on any changes CMS has made to outpatient payment in the 2026 OPPS final rule?

Bob: Sure. If you remember back in the federal fiscal year 2025 inpatient final rule presentation that we did, CMS had finalized the inclusion of the 25th percentile rule, otherwise known as a low wage index hospital policy. A couple of days after that presentation, CMS came out with an interim final rule with comment period, removing the low wage index hospital policy from the federal fiscal year 2025 inpatient prospective payment system regulations in response to ongoing litigation. Now, in the calendar year 2025 OPPS final rule, CMS had once again finalized the inclusion of the low wage index policy to be applied to OPPS payments. CMS recognized that that would mean that some hospital facilities would have a different wage index for calculating their outpatient claims than they had for calculating their inpatient claims. So, in the calendar year 2026 OPPS final rule, CMS has implemented the realignment by eliminating the low wage index policy from the OPPS payments. CMS is using the same methodology they did in the federal fiscal year 2026 IPPS final rule, utilizing the 5% cap and wage index reduction from the prior year for those hospitals affected by this policy change.

Kelly: Thank you, Bob. That’s very interesting. Another major program for hospitals is the 340B program. Can you tell us about the changes in the coming year triggered by the program?

Bob: Sure. There are two major changes to reimbursement relating to the 340B program starting in calendar year 2026. The first is the 340B remedy recruitment fix, which is related to the conversion factor that we just mentioned. It’s for the conversion factor increase for calendar years 2018 through 2022. CMS had previously, in the proposed rule, stated a 2% decrease in the calendar year 2026 conversion factor in order to accelerate the recoupment of the $7.8 billion in additional payments to hospital facilities. In the calendar year 2026 final rule, CMS did not finalize the 2% reduction, but decided to stay with the original 0.5% or half percent decrease in the calendar year 2026 conversion factor as originally stated in the remedy document published on November 8th, 2023. CMS also reserved the right to increase this reduction in future years. Now, the second change to the 340B program for calendar year 2026 was published on August 7th, 2025, by HHS and HRSA and involves a shift in funds for providers by moving to a backend rebate-style pilot program instead of an upfront discount program for 10 drugs that are listed on the CMS Medicare drug price negotiation selected drug list.

For these 10 pharmaceuticals, providers will have to pay full WAC or wholesale acquisition costs pricing when purchasing these drugs. Once the product is sold and the provider applies for the rebate, the drug costs will be reduced to the lower cost of the 340B ceiling price or the Medicare maximum fare price. If the model is fully implemented at a 340B program, it could mean millions of dollars being postponed to 340B providers. The rationale for this program is the adage from the manufacturers about duplicate discounts and diversion that is happening in the program.

Kelly: Well, thank you for sharing that with us. I know the 340B program, there’s always something going on with that. There’s some discussion on changes to the way hospital outpatient departments are being paid in calendar year 2026. Do you have any details on those changes?

Bob: Well, I believe you’re referring to what is called the method to control unnecessary increases in volume of outpatient services furnished and accepted off-campus provider-based departments, which we have shortened to simply site-neutral payments. CMS has stated in the final rule that there was evidence that increased volume and intensity of certain covered outpatient department services, which was likely driven by financial incentives to furnish services in hospitals in order to receive higher reimbursement than making site of service decisions based on medical necessity. For calendar year 2026, CMS decided to pay accepted hospital outpatient departments as if they were non-accepted or freestanding clinics at the Medicare physician fee schedule reimbursement rates instead of the OPPS rates for anti-HCPCS codes assigned to drug administration services, AAPCs. CMS published the specific APCs affected in table 121 of the final rule. And something else to watch here is that there is discussion in the final rule of applying this provision to on-campus hospital outpatient department.

Kelly: Okay. But isn’t CMS doing away with the inpatient-only list? How is that going to affect the outpatient volumes and inpatient services?

Bob: Well, that’s a good point. In the calendar year 2026 OPPS final rule, CMS finalized the elimination of the inpatient-only list over the next three years. This means that more procedures will be done in an outpatient setting, increasing volumes. It will be interesting to watch and see how payments made to hospitals, outpatient departments, and ambulatory surgical centers evolve over time, and whether site neutrality will eventually be implemented in some form to ASCs. And I want to shift gears there for a second, but there’s another aspect with the elimination of the inpatient-only list. And that is the indefinite exemption of site of service claim denials due to the two-midnight rule. As procedures migrate to the outpatient setting, CMS is relying on the physician’s determination as to whether a procedure removed from the inpatient-only list should be done in an inpatient or outpatient setting. If done in an inpatient setting, auditors are not to use the two-midnight rule as a determination for denial of payment at this time. Once CMS determines the procedure to be an outpatient procedure, they will communicate the reinstatement of the rule towards that procedure.

Kelly: So, kind of switching gears a bit here. So, in some of your previous webinars, you discussed up-and-coming activities that could be changing and items we need to keep an eye on. So can you share any areas our audience may need or want to watch?

Bob: First, I would say we should keep an eye on the 340B remedy reduction amount. CMS has given us warning they could increase the reduction of the conversion factor in later years. Next, I would watch for additional site-neutral payment policies. As they have progressed to the excluded provider-based sites for drug administrative services, CMS may choose to apply that policy to other services or to on-campus clinic sites. And lastly, we visit this every year, and that’s pay-go sequestration. The additional Medicare 4% statutory pay-as-you-go sequestration was scheduled to go into effect in January of 2026. Congress has, over the years, continued to keep this program from going into effect, either by wiping the scorecard clean or by using other devices to avoid triggering the sequester. In the continuing resolution that passed in November of 2025, the current administration followed the same practice as the prior administration and wiped the scorecard clean of the $3.4 trillion of deficit spending over the next 10 years. And so it will not go into effect in January of 2026. The reason we need to continue to watch this is twofold. First, it is potentially a drastic cut to Medicare spending as long as the provision remains in the regulations. And second, that Congress could at some point implement it to control over spending.

Kelly: That makes sense. Well, thanks so much for sharing that with us. And thanks for joining us, Bob, today, and for giving us this sneak peek into BESLER’s upcoming webinar, 2026 OPPS Final Rule Summary, that you’re presenting live on Wednesday, January 14^th, at 1 PM eastern time. And as a bonus, you can earn CPE. Thanks again, Bob.

Bob: Thank you, Kelly. Have a great day.

Kelly: Thank you. And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…

If you have a topic that you’d like us to discuss on The Hospital Finance Podcast or if you’d like to be a guest, drop us a line at update@besler.com.

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