Latest / Becker’s Healthcare Podcast / The Next Phase of Federal Independent Dispute Resolution: What RCM Leaders Should Be Building Now

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The Next Phase of Federal Independent Dispute Resolution: What RCM Leaders Should Be Building Now · Becker’s Healthcare Podcast

• 0:00
  - Hello, everyone. This is Erica Spicer Mason with
• 0:02
  - Becker's Healthcare. Thank you so much for tuning
• 0:05
  - in to the Becker's Healthcare podcast series.
• 0:08
  - Today, we're going to talk about the next
• 0:09
  - phase of federal independent dispute resolution
• 0:13
  - and what RCM leaders should be building right
• 0:15
  - now. So joining me for this conversation, we
• 0:18
  - have two leaders from Aspirion.
• 0:20
  - We have Chase McGrath, the vice president of
• 0:23
  - product, and Nikki Richson, the senior director of
• 0:26
  - payment variance.
• 0:27
  - Chase, Nikki, so thrilled to have you with
• 0:30
  - us today.
• 0:31
  - To get us kicked off here, would you
• 0:33
  - both take just a moment to introduce yourselves
• 0:35
  - and tell us a little bit about your
• 0:37
  - background?
• 0:38
  - Chase, would you like to get us started?
• 0:40
  - Yeah. Happy to. So my name is Chase.
• 0:43
  - As mentioned, I lead product development. And, really,
• 0:46
  - my day to day is just involved in
• 0:48
  - trying to figure out
• 0:49
  - what are the business problems out there, what
• 0:51
  - are my RCM operational leaders trying to grapple
• 0:54
  - with, and how can technology
• 0:56
  - solve those problems, and then bring that through
• 0:58
  - to fruition.
• 1:00
  - Fantastic. Great to have you with us, Chase.
• 1:02
  - Thank you. And Nikki, tell us a little
• 1:04
  - bit about you. Hi, everyone. I'm Nikki Richson,
• 1:07
  - senior director of Payment Variance.
• 1:09
  - I've been in the revenue cycle space for
• 1:11
  - over ten years and have worked directly within
• 1:14
  - the No Surprises Act since it first took
• 1:16
  - effect in 2022.
• 1:18
  - It's been an evolving process from those early
• 1:21
  - days to where we are today, so I'm
• 1:22
  - excited to talk about what we've learned along
• 1:24
  - the way and what's changed and where I
• 1:26
  - think we're headed next.
• 1:28
  - Yeah. Nikki, thank you so much. And, you
• 1:30
  - know, you really got us started there on
• 1:32
  - the note that I was hoping we could
• 1:34
  - open up on, which is
• 1:36
  - really grounding our listeners in the No Surprises
• 1:39
  - Act. As you mentioned, it took effect
• 1:42
  - several years ago in 2022.
• 1:44
  - And
• 1:45
  - as you,
• 1:46
  - hinted into that, it's there have been some
• 1:48
  - changes since. So I'd love to hear from
• 1:51
  - you on what has changed the most for
• 1:54
  - providers between those early days of federal IDR,
• 1:57
  - and what did the industry learn the hard
• 2:00
  - way across those changes?
• 2:02
  - Mhmm. Thanks, Erica. We have come a long
• 2:05
  - way in the past several years,
• 2:07
  - and still growing and evolving every day. Never
• 2:09
  - a dull moment in in this space or
• 2:11
  - really health care in general.
• 2:14
  - A few, you know, key things that have
• 2:17
  - we've really learned in the last couple of
• 2:18
  - years. So first, when it comes to IVR
• 2:21
  - eligibility,
• 2:22
  - knowing the difference between state and federal,
• 2:26
  - really has to be determined before
• 2:28
  - submission
• 2:29
  - not after.
• 2:30
  - We also have learned that deadlines are
• 2:34
  - completely unforgiving, so we really have to monitor
• 2:37
  - and track those,
• 2:38
  - with a 100% accuracy.
• 2:41
  - We know that the QPA, the qualifying payment
• 2:44
  - amount is important
• 2:46
  - but the case cannot start and stop with
• 2:48
  - the QPA, there's other factors that need to
• 2:50
  - be considered.
• 2:52
  - We know that templates can help you scale
• 2:54
  - but
• 2:55
  - blind templating can really hurt you.
• 2:58
  - We know that, you know, providers,
• 3:01
  - typically cannot manage the federal IDR
• 3:04
  - or the IDR process in general exclusively
• 3:07
  - inside a traditional EHR or patient account work
• 3:10
  - queue.
• 3:11
  - And the one of the biggest things,
• 3:14
  - that we're all still learning and and,
• 3:16
  - dealing with today is that winning
• 3:19
  - the determination is not the end of the
• 3:21
  - process.
• 3:22
  - Nikki, it's pretty remarkable
• 3:25
  - what you just listed off there. You know,
• 3:26
  - we're we're talking from everything
• 3:28
  - from that basic knowledge of
• 3:30
  - knowing whether it's a state or a federal
• 3:33
  - matter,
• 3:34
  - deadlines being unforgiving.
• 3:37
  - So appreciate you kind of setting the scene
• 3:39
  - on what providers are facing in this realm.
• 3:43
  - And I know in line with some of
• 3:44
  - these changes that we've hinted at already, we've
• 3:47
  - seen that CMS has released the federal IDR
• 3:49
  - operations final rule back in May of this
• 3:52
  - year.
• 3:53
  - So I'd love to hear from both of
• 3:54
  - you on this. What stands out to you
• 3:56
  - as the most consequential
• 3:58
  - change in that latest May update for providers?
• 4:02
  - Absolutely. I'll kick us off here. So I
• 4:04
  - think that one of the most consequential
• 4:06
  - is the federal IDR gateway portal.
• 4:10
  - This will be a one stop hub for
• 4:12
  - federally
• 4:13
  - eligible negotiations
• 4:14
  - and IDR submissions.
• 4:16
  - The process visibility and streamline capabilities
• 4:19
  - paired with improved tracking will greatly improve
• 4:23
  - the current process and
• 4:25
  - be incredibly helpful for everyone in this space.
• 4:28
  - Super helpful for you to raise up the
• 4:30
  - portal, Nikki, and Chase. Is there anything else
• 4:32
  - that you would add here?
• 4:34
  - Yeah. I actually think there's a few things
• 4:36
  - that are pretty interesting,
• 4:37
  - coming out of those changes,
• 4:39
  - pending the final rule change.
• 4:42
  - So the fee structure, the batching, and then
• 4:44
  - that reviewer entity selection, I think, really
• 4:47
  - enable parties to pursue more cases with the
• 4:50
  - health technology,
• 4:51
  - much more so than in the past. And
• 4:53
  - then that standardization
• 4:55
  - of, remittance codes, so requiring that payers use
• 4:58
  - standard codes similar to what we kinda see
• 5:01
  - in the denial space, That also addresses, I
• 5:03
  - think, a pretty major triage issue that we
• 5:05
  - saw in the workflow where even trying to
• 5:07
  - find these cases when they come in to
• 5:09
  - understand what's eligible for the process was was
• 5:11
  - pretty difficult. So that allows, I think, across
• 5:14
  - the spectrum,
• 5:16
  - quite a bit of standardization,
• 5:18
  - automation to be put in place, and to
• 5:20
  - allow things to kind of flow on more
• 5:22
  - of a technology
• 5:24
  - sort of conveyor belt throughout the entire process.
• 5:27
  - And we also believe that just with proper
• 5:29
  - analytics in place,
• 5:30
  - this all opens up the opportunity for
• 5:33
  - better case prioritization,
• 5:35
  - submission matching, and then entity routing to basically
• 5:39
  - optimize the process down the road based on
• 5:41
  - what we see working with those initial submissions
• 5:44
  - once the changes are live and and being
• 5:46
  - able to really learn from those.
• 5:48
  - Yeah. Chase, I appreciate
• 5:50
  - what you've just touched on because I think
• 5:53
  - if I'm picking up what you're saying, it
• 5:54
  - it sounds like these changes have really put
• 5:57
  - to the forefront that technology infrastructure
• 6:00
  - needs to be able to adapt,
• 6:02
  - to really uphold some of these
• 6:04
  - latest changes and rules.
• 6:06
  - And before we get deeper into that, Nikki,
• 6:09
  - I wanted to go back to you just
• 6:10
  - for a moment here. I know you mentioned
• 6:12
  - the the federal IDR gateway portal. Since this
• 6:14
  - is something newer, would you mind sharing just
• 6:16
  - a little bit more about that portal with
• 6:18
  - our listeners who this may be news to
• 6:20
  - them?
• 6:22
  - Yes. Absolutely.
• 6:23
  - So currently,
• 6:25
  - when working with
• 6:27
  - federally eligible IDR submissions, you know, the process
• 6:31
  - is a little clunky
• 6:32
  - in sorts where,
• 6:34
  - you are typically emailing off to
• 6:38
  - a distribution box on the the payer side.
• 6:40
  - We're, you know, working,
• 6:42
  - with CMS and submitting
• 6:45
  - forms and submissions through there.
• 6:47
  - So you have a lot of pieces of
• 6:50
  - the process puzzle that are broken up, and
• 6:52
  - this portal is really going to tie it
• 6:54
  - in nicely together. I think this is also
• 6:56
  - very helpful for any organizations that are using
• 7:00
  - vendors in this space.
• 7:02
  - This portal is going to be, like I
• 7:04
  - had mentioned that one stop, you know, shop
• 7:06
  - that hub
• 7:08
  - where
• 7:09
  - federally eligible negotiations
• 7:11
  - will start
• 7:12
  - in this portal. Everyone will have visibility that
• 7:15
  - has access,
• 7:16
  - whether it's a vendor, another third party,
• 7:19
  - the organizations,
• 7:20
  - CMS as well, and it gives everyone the
• 7:23
  - ability to track, monitor.
• 7:26
  - You can look at reporting capabilities
• 7:29
  - for what's winning and what's losing, any additional
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  - trends,
• 7:33
  - any issues that are are
• 7:35
  - taking place. And then you have that next
• 7:37
  - step of those federally eligible,
• 7:40
  - claims of the negotiation period,
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  - ends. Unfortunately, a resolution was not able to
• 7:46
  - be met, so therefore, throughout the same portal,
• 7:49
  - you can then move into
• 7:51
  - the IDR
• 7:52
  - process. The IDR entities will be,
• 7:55
  - in this portal as well. So, of course,
• 7:58
  - streamlined, you know, communication and identification
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  - there.
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  - And it all just stays in one
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  - one hub that will make things a lot
• 8:06
  - easier for everyone and and less less contact
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  - confusion,
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  - which I think will be incredibly helpful. And
• 8:12
  - again, just the overall visibility will really help
• 8:15
  - connect
• 8:16
  - all, players in this space.
• 8:19
  - Mhmm.
• 8:20
  - Yeah. Nikki, thanks so much for
• 8:22
  - clarifying that. Really helpful to know.
• 8:25
  - And I know that, Nikki, both you and
• 8:28
  - Chase have have touched on this idea that
• 8:31
  - federal IDR and then the processes that it
• 8:34
  - entails do not necessarily
• 8:36
  - fit neatly into traditional,
• 8:39
  - technology infrastructure like the EHR or revenue cycle
• 8:42
  - workflows.
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  - So I'd like to hear from you both
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  - on where this work
• 8:48
  - lives inside of a provider organization, and and
• 8:51
  - what are you seeing breakdown when teams try
• 8:53
  - to manage it with their existing tools and
• 8:56
  - processes?
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  - Mhmm.
• 8:58
  - Absolutely.
• 8:59
  - You know, today, we see that for many
• 9:01
  - organizations,
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  - it still lives in those traditional,
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  - work queues and EHRs
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  - right alongside
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  - normal, you know, claims follow-up,
• 9:12
  - and account resolution work.
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  - We also see organizations
• 9:16
  - that are continuing
• 9:18
  - to,
• 9:19
  - try to adapt to better identifying and managing
• 9:21
  - this process.
• 9:23
  - However, that has meant that these claims and
• 9:26
  - accounts are living on spreadsheets.
• 9:29
  - So those spreadsheets and in those traditional work
• 9:32
  - queues, you know, that relies really heavily on
• 9:35
  - manual entry, and it does require a 100%
• 9:38
  - accuracy
• 9:39
  - to ensure that everything is identified correctly,
• 9:42
  - deadlines aren't missed, fees
• 9:45
  - are paid timely.
• 9:46
  - So there's a lot of of room for
• 9:49
  - error in in the current traditional spaces.
• 9:52
  - And, Nikki, thanks for for shedding some light
• 9:55
  - on where you're seeing this process
• 9:57
  - hit its limitations at at organizations.
• 9:59
  - Chase, how does this compare to what you're
• 10:01
  - seeing on the ground?
• 10:03
  - Yeah. So like Nikki mentioned, you know,
• 10:05
  - spreadsheets seem to be the order of the
• 10:07
  - day at a lot of organizations. And and,
• 10:09
  - really, that's because
• 10:11
  - EHRs don't really support this type of a
• 10:14
  - life cycle. They're really built around,
• 10:17
  - obviously, the clinical workflows and then traditional RCM
• 10:20
  - workflows, but they're not really built to manage
• 10:22
  - dispute life cycles.
• 10:24
  - So we getting into this space, there was
• 10:26
  - really a need to create that structure
• 10:28
  - and build sort of our own version of
• 10:30
  - this workflow platforming
• 10:31
  - that was designed around that dispute life cycle.
• 10:34
  - We didn't really see anything in the market
• 10:36
  - to address this, And so kind of having
• 10:38
  - that custom built technology
• 10:40
  - that's designed to manage the deliverables, the deadlines,
• 10:43
  - the sort of key steps, as well as
• 10:46
  - those really tight timelines that we see in
• 10:47
  - the IDR process
• 10:49
  - What was sort of an imperative to be
• 10:51
  - a credible player in this space.
• 10:53
  - And, you know, with the technology in place,
• 10:55
  - we now have process discipline
• 10:57
  - at scale that ensures quality and consistency of
• 11:00
  - submissions,
• 11:01
  - and then making sure that you meet all
• 11:02
  - those requirements and deadlines,
• 11:05
  - and then, of course, still leveraging human experts
• 11:07
  - for review of outputs and kind of final
• 11:09
  - approval on those packages
• 11:10
  - before they go out for submission.
• 11:12
  - So, certainly, it's a challenge we saw.
• 11:15
  - We know a lot of other organizations are
• 11:16
  - trying to figure out what's the best way
• 11:18
  - to manage this, and I'm sure seeing that,
• 11:20
  - hey, hey. My traditional EHR, EMR just really
• 11:23
  - isn't up to the task because it's it's
• 11:25
  - really designed to solve a different problem.
• 11:28
  - Absolutely. I mean, everything that you both have
• 11:30
  - described already,
• 11:32
  - the word dynamic comes to mind whether we're
• 11:34
  - talking about federal IDR
• 11:36
  - itself and and the changes that we see
• 11:38
  - on a regular basis, but then down to
• 11:40
  - the requirements that you're speaking to, meeting deadlines,
• 11:43
  - ensuring submissions have full documentation and are compliant.
• 11:48
  - It it's a lot for
• 11:50
  - any one system to handle. So,
• 11:52
  - Chase, I'll stick with you for this next
• 11:54
  - question.
• 11:55
  - As we see federal IDR continuing to change,
• 11:59
  - what specific capabilities do you think providers should
• 12:01
  - look for in a technology or a services
• 12:04
  - partner to ensure that they're staying compliant without
• 12:07
  - constantly rebuilding their workflows?
• 12:10
  - Yeah. And as you said, right, the keyword
• 12:12
  - is dynamic, and things are dynamic in this
• 12:16
  - space. We've seen changes this year.
• 12:18
  - We anticipate things will evolve over time as,
• 12:21
  - you know, the regulators learn and get feedback
• 12:24
  - from the industry. So I think the the
• 12:26
  - key things to keep in mind are that
• 12:28
  - the systems have to be configured to ensure
• 12:30
  - compliance at scale. So that way, you know
• 12:32
  - you're following the process
• 12:33
  - consistently each and every time, and then also
• 12:36
  - updating rules and logic and and sort of
• 12:39
  - business process orchestration
• 12:41
  - as needed when those things change, when regulatory
• 12:44
  - requirements evolve, your business needs change,
• 12:47
  - so it's sort of keeping pace. So I
• 12:50
  - would say a strong partner will have a
• 12:51
  - product leader or really a product function that's
• 12:54
  - working with those customers directly
• 12:56
  - to just ensure that platforms and workflows are
• 12:59
  - staying up to date with those changes. And
• 13:01
  - when you work with a partner, you know,
• 13:02
  - you should have the expectation that they're the
• 13:04
  - ones staying on top of industry changes.
• 13:06
  - They're the ones taking a proactive approach to
• 13:08
  - compliance, and and they're really sort of putting
• 13:10
  - you at ease and ensuring that as your
• 13:13
  - partner, you know, you're already ahead of the
• 13:15
  - game. Right? That that's really what you're paying
• 13:16
  - for.
• 13:18
  - Yeah. Chase, I I appreciate how you outlined
• 13:20
  - those capabilities so clearly, and it it definitely
• 13:25
  - I I can see how this would warrant
• 13:26
  - additional support from a partner,
• 13:28
  - just to simply navigate the complexity that comes
• 13:31
  - along with federal IDR.
• 13:33
  - It's been a great conversation
• 13:35
  - with you both today. I know we've covered
• 13:37
  - a lot of ground in a short time,
• 13:39
  - but I'm curious if there's anything else that
• 13:42
  - we haven't covered that you think our listeners
• 13:44
  - should walk away with or even any final
• 13:47
  - thoughts that you'd like to,
• 13:50
  - that you'd like to leave them with. So
• 13:51
  - I'll open up the floor to you both
• 13:53
  - for those final takeaways.
• 13:55
  - Thank you so much, Erica, for meeting with
• 13:58
  - us today and and going over these topics.
• 14:00
  - I do have a couple of things that
• 14:02
  - I think are really important,
• 14:04
  - some key dates
• 14:05
  - coming up that providers should be aware of.
• 14:08
  - First is September 15
• 14:10
  - is the phase one of the federal IDR
• 14:13
  - portals
• 14:14
  - release starting with the administrator
• 14:17
  - level account creation.
• 14:19
  - The portal itself is supposed to launch before
• 14:21
  - the end of this year, 2026.
• 14:23
  - So phase one administrator
• 14:26
  - account creation, September 20 or sorry, September 15.
• 14:30
  - Also, effective January 1, there are nine new
• 14:33
  - NSA
• 14:35
  - related RAR codes.
• 14:36
  - Those codes have already been released.
• 14:39
  - CMS did a press release on them so
• 14:41
  - you can find more information.
• 14:43
  - But we do urge organizations to begin building
• 14:46
  - and updating their current NSA identification
• 14:49
  - processes now to get ahead of the January
• 14:52
  - 1,
• 14:53
  - implementation.
• 14:55
  - Nikki, thank you so much for highlighting those
• 14:57
  - key dates for our listeners.
• 14:59
  - Chase, eager to hear your final thoughts here
• 15:02
  - too.
• 15:03
  - Yeah.
• 15:04
  - Thanks to you both, for, you know, the
• 15:06
  - input from Nikki and then just for having
• 15:07
  - us here for this conversation. So
• 15:10
  - I think I would just finish this out
• 15:11
  - by saying, as Nicky pointed out, these changes
• 15:14
  - are coming really soon. So I would either
• 15:16
  - start engaging those internal technology and product partners
• 15:19
  - to be ready,
• 15:21
  - as these things come to fruition or look
• 15:23
  - for a vendor immediately because,
• 15:26
  - time is definitely running out.
• 15:28
  - Yeah. Time is at the essence.
• 15:30
  - Well, thank you both so much again for
• 15:32
  - everything that you shared with our listeners today.
• 15:35
  - A lot of really grounded
• 15:38
  - advice and reminders here in this conversation.
• 15:40
  - So, again, thanks so much for making the
• 15:43
  - time to join Becker's today. Thanks, Erica.
• 15:46
  - Thank you.
• 15:47
  - And, of course, we'd also like to thank
• 15:49
  - our sponsor for today's session, Aspirion.
• 15:52
  - Listeners, be sure to tune in to more
• 15:54
  - podcasts from Becker's by visiting our podcast page
• 15:57
  - at beckershospitalreview.com.