Hannah Maroney, Legal Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/hannah-maroney/ Your modern revenue cycle solution Tue, 18 Mar 2025 16:13:25 +0000 en-US hourly 1 https://www.ensemblehp.com/wp-content/uploads/2023/10/Logo-Chevron-80x80.png Hannah Maroney, Legal Counsel, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/hannah-maroney/ 32 32 Tracking Recently Enacted State Laws That Impact the Revenue Cycle https://www.ensemblehp.com/blog/tracking-recently-enacted-state-laws-that-impact-the-revenue-cycle/ Mon, 29 Jul 2024 13:37:54 +0000 https://www.ensemblehp.com/?p=14388 Many bills have been pending in state legislatures. Let’s take a look at what’s been recently enacted in three of those states. … Read More

The post Tracking Recently Enacted State Laws That Impact the Revenue Cycle appeared first on Ensemble Health Partners.

]]>

Here at Ensemble Health Partners, our experts keep a close eye on regulatory updates in the healthcare industry that could impact revenue cycle processes. This helps to keep our operators informed as well as to ensure our partners can stay one step ahead of shifting legislation.

In follow-up to our recent article on topics and bills that were pending in state legislatures, let’s take a look at what’s been recently enacted in three of those states.

Florida

Transparency in Health and Human Services:
This legislation includes:

  1. new requirements with respect to the collection of medical debt, including the imposition of a 3-year statute of limitations, and restrictions against taking “extraordinary collection actions” which include preemptively engaging in certain collection actions (e.g. selling debt, credit reporting, etc.) prior to meeting certain requirements (e.g. providing an itemized bill, making reasonable efforts to check eligibility for financial assistance, etc.
  2. new requirements for the provision of good faith estimates*; and
  3. new billing requirements, including required disclosures for cost sharing amounts as compared to cash payments for the same service/item, the establishment of an internal process for reviewing and responding to grievances from patients (the process must also allow a patient to dispute charges that appear on the patient’s itemized statement or bill and provide directions for doing so in bolded print on the bill).

*Note that the requirements for good faith estimates are not effective until the federal government issues a corresponding rule.

Maine

An Act to Provide for Consistent Billing Practices by Health Care Providers:
This new law requires that claims for facility services submitted to health insurance carriers identify the physical location where services are rendered, including hospital off-campus locations.

An Act to Amend the Maine Insurance Code Regarding Payments by Health Insurance Carriers to Providers:
This new law restricts health insurance carriers to filing notices of a proposed amendment to a provider agreement to only four time per calendar year: on January 1, April 1, July 1 and October 1.

If the proposed change is to a reimbursement policy and it will impact more than $500k per year to participating providers, then the notice must include the carrier’s good faith estimate of the total annual financial impact to all participating providers in the state.

Carriers will need to furnish the participating provider with both a clean and redlined copy of the provider agreement being changed. This bill also shortens the time limits for carriers to retroactively deny previously paid claims to not more than 12 months. Situations exempt from the 12-month timeframe will now be subject to a 36-month limit.

An Act to Protect a Patient’s Access to Affordable Health Care with Timely Access to Health Care Prices:
This new law requires health care facilities and practitioners to post a notice informing patients of the right of an uninsured patient to request information about the price of medical services, and to include the notice in the consent-to-treatment form that patients sign before receiving health care services. Upon request of an uninsured or self-pay patient, the new law requires facilities and providers to furnish a good faith estimate of the cost of medical services for that single encounter within specified timeframes.

To a certain extent, these requirements align with current requirements under the Federal No Surprises Act (NSA), and a health care entity does not violate this state law if it complies with NSA requirements. If the provider fails to give an uninsured or self-pay patient a good faith estimate upon their request, then the provider is prohibited from initiating or pursuing any collection action against that patient for those items or services.

This new law also requires the provision of a description of services for a single encounter to insured patients upon their request. The description must include the CPT codes for the services and a notification that the patient may use the estimate to obtain an estimate of their out-of-pocket costs from their health insurance carrier. Carriers are then required to respond to requests from a patient for an estimate based on the description and codes given by the provider.

Lastly, the new law requires hospitals to comply with federal price transparency requirements.

An Act to Prohibit Unfair Practices Related to the Collection of Medical Debt:
This new law prohibits unfair practices related to the collection of patient medical debt, including the collection of any interest or fees on the debt.

If pursuing litigation to compel payment of medical debt, the new law requires providing the patient with a certain written notice indicating that litigation may not be pursued when the consumer’s household income is not more than 300% of the federal poverty level, and then allowing the consumer 30 days to respond and provide evidence of their income.

An Act Concerning Prior Authorizations for Health Care Provider Services:
This new law permits a provider who is actively treating an enrollee to act as their representative for purposes of filing an appeal or grievance without requiring prior authorization from the enrollee. The provider, however, must furnish the enrollee with notice of such at least 14 days prior to filing the appeal or grievance and within 7 days after filing, and the enrollee may affirmatively object to such representation.

This new law requires carriers to allow prior authorizations to be effective for 14 days before or after the approved date if the service cannot be delivered on the approved date. For non-emergency services, the new law prohibits carriers from denying claims for those services so long as they were within the scope of the enrollee’s coverage pending medical necessity review. Carriers may also not impose a penalty on the provider for failing to obtain a prior authorization of greater than 15% of the contractually allowed amount for the services that required prior authorization approval.

This new law prohibits carriers from requiring prior authorization for post-evaluation or post-stabilization services provided during the same encounter. If post-evaluation or post-stabilization services require inpatient care, then the carrier may require prior authorization but it must respond to the prior authorization request within 24 hours. If the provider does not receive a determination within that 24-hour period, then the care is deemed approved until the carrier notifies the provider otherwise.

Lastly, this new law imposes new reporting requirements on carriers relating to prior authorization determinations, which will be collected by the Bureau of Insurance and reported to the Maine Legislature in 2025.

Virginia

An Act relating to health insurance; ethics and fairness in carrier business practices.
This bill made various amendments to Va. Code § 38.2-3407.15, Ethics and Fairness in Carrier Business Practices, including revisions to the definition of a “clean claim.” Regarding retroactive denials of previously paid claims, this was broadened to include any way in which a carrier may seek recovery or refund of a previously paid claim. The time limit is 12 months except that a provider and carrier may agree to longer than 12 months for a retroactive denial. If a carrier’s claim denial is overturned following a dispute review, the carrier must consider the claim be a “clean claim” on the day of its decision.

A newly enacted provision prohibits providers from filing a complaint with the State Corporation Commission for a carrier’s failure to pay claims as required unless the provider attests that they have made a reasonable effort to resolve the issue with the carrier and at least 30 calendar days have passed without response from the carrier.

An Act relating to health insurance; prior authorization.
Requires provider-carrier contracts to include a specific provision that if a prior authorization request is approved for prescription drugs and such prescription drugs have been scheduled, provided or delivered to the patient consistent with the authorization, the carrier shall not revoke, limit, condition, modify or restrict that authorization except in certain limited situations.

An Act relating to reporting of medical debt to consumer reporting agencies by certain health care providers.
Prohibits facilities and providers from reporting any portion of medical debt to a consumer reporting agency. Further, collection entities collecting or attempting to collect a medical debt are prohibited from reporting such collection or attempts to a consumer reporting agency. Any willful violation of this new section constitutes a prohibited practice under the Virginia Consumer Protection Act.

An Act to amend relating to health insurance; health care provider panels; continuity of care.
Requires a provider to continue to render health care services to any of the carrier’s enrollees who have an existing provider-patient relationship with the provider for a period of at least 90 days from the date of a provider’s termination from the carrier’s provider panel. Longer periods required for patients who are pregnant or terminally ill, who have a life-threatening condition or who have been admitted inpatient.

Keeping you informed

Close monitoring of changing regulations is critical for the financial health of our clients and for any healthcare provider. Ensemble is committed to tracking new legislation as it is drafted and passed. 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

RELATED CONTENT

The post Tracking Recently Enacted State Laws That Impact the Revenue Cycle appeared first on Ensemble Health Partners.

]]> Revenue Cycle Impacts: 2024 State Legislation https://www.ensemblehp.com/blog/revenue-cycle-impacts-2024-state-legislation/ Tue, 30 Apr 2024 13:38:14 +0000 https://www.ensemblehp.com/?p=12959 State legislatures have already been busy this year. Here are some topics and bills Ensemble experts have been watching closely. … Read More

The post Revenue Cycle Impacts: 2024 State Legislation appeared first on Ensemble Health Partners.

]]>

At Ensemble Health Partners, we track regulatory updates in the healthcare industry to keep our operators informed and ensure our partners have the information they need to stay ahead of the changing legislation.

It’s still early in 2024, but state legislatures have already been busy this year. Here are some topics and bills that our experts have been watching closely.

Patient Medical Debt Collection

  • Connecticut – Raised SB 395 would prohibit health care providers from reporting medical debt to credit rating agencies. It would also require providers to include in any contracts with debt collection entities a provision which would prohibit those entities from credit reporting. This legislation has so far passed the Senate. If it becomes law, it would be effective July 1, 2024.
  • Florida – HB 7089 establishes a three-year statute of limitations to collect medical debt, and exempts medical debt from legal process including attachment, garnishment, or legal process in an action on medical debt. This bill has passed the legislature but has not yet been presented to Governor Ron DeSantis as of the conclusion of the 2024 Regular Session. Once presented, Governor DeSantis will have 15 days to take action.
  • Maine – SP 908 prohibits health care providers from charging any interest on debt or fees in connection with collection of medical debt. It also prohibits debt collectors from pursuing litigation to compel payment of medical debt without providing proof that the consumer was sent a certain written notice, given at least 30 days to respond, and when the consumer’s household income is not more than 300% of the Federal poverty guidelines. This bill was recently approved by the governor and will become effective 90 days after adjournment of the legislative session.
  • New Jersey – A3760 or the “Medical Debt Homestead Protection Act” prohibits forced home sales in cases of bankruptcy resulting from medical debt. S2806/A3861 or the “Louisa Carman Medical Debt Relief Act” prohibits medical debt collectors from reporting medical debt to consumer reporting agencies as of the effective date (not provided), as well as prohibits consumer reporting agencies from reporting medical debt less than $500 regardless of when the debt was incurred. A3513 caps the medical debt interest rate as the lessor of (i) “the annual rate equal to the weekly average one-year constant maturity Treasury yield, as published by the Board of Governors of the Federal Reserve System, for the calendar week preceding the date when the consumer was first provided with a bill” or (ii) 3%. All bills are pending committee review.
  • South Carolina – HB 4571 would prohibit consumer credit reporting agencies from using in its consumer credit report any information concerning medical debt. This bill has been with the House Committee on Labor, Commerce and Industry since January.
  • Tennessee – HB 1957 would prohibit consumer reporting agencies from including on a consumer report a record of medical debt. It would also require providers and facilities to ensure that any amount of outstanding patient date that equals the amount of public funds accepted is designated as satisfied and that patient is notified of such satisfaction of their debt. Lastly, it would prohibit providers and facilities from seeking judgment or taking other legal action to collect medical debt. This bill recently failed in the Senate Commerce and Labor Committee.
  • Virginia – Virginia passed two new laws relating to medical debt during its session. HB 1370 prohibits facilities, providers, emergency medical services agencies, and debt collection entities from reporting any portion of a medical debt to a consumer reporting agency. HB 34 establishes a three-year statute of limitations from the final invoice due date to collect medical debt unless there is a contract for a payment plan that allows for a long period of time for collection. Where there is a breach of a payment plan, an action is barred if not started within three years from the date of breach. Both laws become effective July 1, 2024.
  • Wisconsin – AB 786 would have prohibited health care providers, billing administrators, and debt collector acting on behalf of the provider from reporting a medical debt to a consumer reporting agency unless 1) the health care provider provided a written statement to the patient describing the unpaid amount and including the name and address of the health care provider that provided the services, 2) six months have passed since the due date listed on that statement, and 3) the patient does not dispute the charges. This bill recently failed to pass the Senate.

Downcoding

  • Connecticut – Raised SB 405 would require payers that contract with a health care provider on or after July 1, 2025, to include in their contract a provision that prohibits the payer from downcoding any claim submitted by the health care provider. This bill is with the Senate, which held a Public Hearing about it in March.
  • Florida – Although these bills died in committee during Florida’s legislative session, HB 1475/SB 1574 would have prohibited insurers from downcoding (unless otherwise permitted in the participation agreement) if the service was ordered by a provider in-network with the applicable health plan. If permitted by the participation agreement, the payment adjudicator would have needed to meet additional requirements.
  • New Jersey – As introduced, Bill S594 and Bill A1036 would prohibit payers from downcoding in a manner that would prevent a health care provider from submitting a claim for the services performed and collecting reimbursement from the payer for that service. Both bills are pending committee review.

Prior Authorization

  • Arizona – HB 2726 would require that, in the event a patient changes insurance, if the prior insurer approved a prior authorization for a covered service, the new health care insurer must also honor the prior authorization for the first 90 days of the member’s health insurance coverage. Also imposes requirements for publication and notification of requirements and changes to the same. Further, makes prior authorization valid for at least six months from the date the health care insurer receives the prior authorization or the length of the treatment and remains in effect regardless of any changes in the prescription dosage. This bill has been assigned to the HHS and Rules Committees and is pending review.
  • Connecticut – Raised HB 5460 would prohibit insurers from (1) requiring prior authorizations after any transport when medically necessary by ambulance to a hospital, and (2) denying payment to ambulance providers on the basis that the enrollee failed to obtain a prior authorization. This bill is currently with the House Joint Committee on Insurance and Real Estate, which held a hearing about it in March.
  • Florida – Although these bills also died in committee during Florida’s legislative session, HB 1475/SB 1574 would have required insurers to establish an electronic prior authorization process for accepting prior authorization requests.
  • Kansas – HB 2713 would impose certain requirements and limitations on the use of prior authorization for healthcare services. This bill has been referred to Committee on Interstate Cooperation and is pending review.
  • Kentucky – HB 317 would have established a prior authorization exemption program including, for example, a requirement that a health care provider be exempted when they have a 90% approval history during a specific timeframe. This proposed “gold card” program was supported by both the Kentucky Hospital Association and the Kentucky Medical Association, but Beckers recently reported that this bill failed.
  • Maine – HP 485/LD 796 requires health plan carriers to establish and maintain a grievance procedure for resolution of prior authorization denials where such procedures must include notice to the enrollee’s provider of a prior authorization denial. The law further requires that if a covered medically necessary service cannot be delivered on the approved date of an approved prior authorization request, a carrier cannot deny the claim if the service is provided within 14 days before or after the approved date. If non-emergency services within scope of a patient’s coverage are provided without a required prior authorization approval, the carrier cannot deny the claim pending medical necessity review and may not impose a penalty on the provider for failing to obtain a prior authorization greater than 15% of the contractually allowed amount for the services. This new law also establishes other requirements and limitations around prior authorization processes and imposes certain new reporting requirements on health carriers about their prior authorization requirements. This bill became law without the governor’s signature on May 1, 2024. Bills in Maine become effective 90 days after the end of the legislative session in which it was passed; here, that will be mid-July.
  • Missouri – SB 983 provides that a health carrier or utilization review entity shall not require health care providers to obtain prior authorization for health care services, except under certain circumstances. Similarly, HB 1976 adds additional requirements for prior authorization, including a 6 month evaluation period, notifications, determination parameters, and online portal access. Both bills are pending committee review and advancement.
  • New Hampshire – SB 561 seeks to establish parameters around the use of prior authorization while also standardizing and streamlining those processes. Among the different requirements, the law would require a prior authorization to be valid for 60 business days from the date of issuance. It would also require, with specific exceptions, that health carriers pay contracted health care providers for a health care service which was provided according to a prior authorization determination. This bill has passed the Senate, and the House Commerce and Consumer Affairs Committee recently held a Public Hearing about it.
  • New Jersey – S530 or the “New Jersey Respect for Physicians Act” seeks to create requirements with respect to promptness of insurer responses to prior authorization requests. This bill has been referred to Senate Commerce Committee and is pending review.
  • New Mexico – SB135 prohibits prior authorization for FDA-approved prescription drug treatment for an autoimmune disorder or cancer (in addition to SUDs, which is currently provided), unless the generic version is available. This bill passed and was signed into law March 1, 2024. The law applies to plans issued for delivery or renewed on or after January 1, 2025.
  • Tennessee – SB 2014 requires that health plans must adhere to 72-hour waiting period prior to imposing as a condition of coverage that the provider promptly contact the health insurer for prior authorization for continued treatment and other care for an enrolled patient. This bill has been referred to the Senate Commerce and Labor Committee.
  • Virginia –SB 98/HB 1134 requires that provider contracts with carriers include a specific provision that prohibits carriers from revoking, limiting, conditioning, modifying, or restricting any prior authorization it approved for a prescription drug which has been scheduled, provided, or delivered to the patient consistent with the authorization. This new law becomes effective July 1, 2024.

Keeping you informed

  • Shifting regulations can be difficult to follow but monitoring them is critical; any impact to the healthcare industry represents an impact to our clients. Ensemble is committed to tracking new legislation as it is drafted and passed. 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

RELATED CONTENT

The post Revenue Cycle Impacts: 2024 State Legislation appeared first on Ensemble Health Partners.

]]> OIG Increases Scrutiny on Medicare Advantage Coding https://www.ensemblehp.com/blog/oig-medicare-advantage-coding/ Fri, 27 Oct 2023 17:46:35 +0000 https://www.ensemblehp.com/?p=12334 Federal agencies are scrutinizing Medicare Advantage coding with inaccurate diagnoses for enrollees with certain high-risk diagnoses. … Read More

The post OIG Increases Scrutiny on Medicare Advantage Coding appeared first on Ensemble Health Partners.

]]>

Federal agencies have recently increased their focus on Medicare Advantage (MA) plan compliance with federal coding requirements, and specifically, the reporting of inaccurate diagnoses codes for enrollees with certain high-risk diagnoses, resulting in increased (though incorrect) payments from Medicare.

So far this year, OIG has audited nine MA plans for coding compliance issues with these high-risk diagnoses codes, and has generally found that MA plans failed to comply with Federal requirements when submitting these codes.

Plan-specific overpayments + false claims

When analyzing a sample audit of Aetna claims, OIG found that patient medical records did not support the diagnoses codes submitted by Aetna. OIG calculates that Aetna is responsible for $632,070 in overpayments associated with the sample reviewed, and as a result estimates that Aetna received at least $25.5 million in overpayments for 2015 and 2016.

Similarly, Cigna has agreed to settle allegations brought by the Justice Department claiming that Cigna violated the False Claims Act by submitting false diagnosis codes and failing to withdraw inaccurate diagnosis codes for enrolled Medicare Advantage patients, resulting in increased Medicare payments.

Specifically, for payment years 2014 to 2019, Cigna allegedly engaged professional healthcare coders to conduct retroactive “chart reviews” which resulted in the submission of previously un-reported additional diagnosis codes to CMS. Moreover, DOJ highlighted that these chart reviews conducted by Cigna also failed to substantiate the diagnoses codes previously submitted by providers before billing Medicare.

Additionally, for payment years 2016 to 2021, DOJ alleges that Cigna “knowingly submitted and/or failed to delete inaccurate and untruthful diagnosis codes for morbid obesity (ICD-10 E66.01 & E66.2, ICD-9 278.01 & 278.03).” As a result, Cigna allegedly utilized the chart reviews to bolster payments with the reporting of additional diagnoses codes while simultaneously failing to report overpayments using the same captured information.

Correction + next steps

OIG recommends that MA plans identify and refund any overpayments while continuing to examine and improve compliance procedures. In July, OIG added to its Work Plan a “Medicare Part C High-Risk Diagnosis Codes Tool Kit.” OIG explained that it will develop this resource to assist MA plans with analyzing the accuracy of data received from providers, and this will be a starting point from which MA plans can research enrollees who receive diagnoses that are at high risk for being miscoded and then take appropriate action as needed.

In light of this increased enforcement activity for MA plans and the OIG toolkit which (when developed) will assist MA plans in analyzing provider coding, it is likely that providers will experience heightened attention in this area, including an increase in pre-payment and post-payment audits by MA plans. As such, from a practical perspective, providers should ensure that proper coding processes and procedures are in place to avoid noncompliance when submitting claims to MA plans.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

RELATED CONTENT

The post OIG Increases Scrutiny on Medicare Advantage Coding appeared first on Ensemble Health Partners.

]]>