InSights 

Uncompensated Care to Increase

Uncompensated care primarily affects hospitals, with an estimated $85 billion in uncompensated care projected between 2025 and 2034. However, non-hospital physicians would see an estimated increase of $34 billion in uncompensated care. Pharmacies would stand to see $56 billion in uncompensated prescription medications.

As you might have guessed, uncompensated care refers to what we traditionally know as uninsured or self-pay patients.

The study which projected the estimates is courtesy of the Robert Wood Johnson Foundation. Click here for the report and its details.

With these dire predictions about uninsured/uncompensated care patients, ADSRCM and ADS clients have access to an accurate insurance discovery option to help ensure they know about any uninsured patients who really do have coverage.)

Value-Based Care = More Revenue

On a more positive note, most healthcare organizations anticipate more revenue from value-based care arrangements over the next year despite specific financial and operational challenges with the alternative payment models.

As you know/as a reminder, value-based care, a movement that began over a decade ago, is an alternative to the traditional fee-for-service healthcare payment system.

A new survey by the National Association of ACOs (NAACOS) finds that 64% of healthcare organizations expect higher revenue from value-based care models in 2025 compared to 2024.

Interestingly, the survey showed that success in value-based care is more likely when unified platforms that integrate clinical, financial, and operational data are used. Systems that support proactive care management add another element to success with value-based care.

Click here for the NAACOS survey.

(Using the ONC-certified MedicsCloud EHR, ADSRCM and ADS clients can use unified platforms as suggested and can have proactive care management alerts also as described. MIPS calculations can be automatically produced for easy reporting. And our MIPS team is available to assist as may be needed.)

AI-Based Assistants

According to Britain’s Lloyds Banking Group, “smart” artificial intelligence (AI)-based assistants could save people two hours daily. To be fair and in the spirit of full disclosure, the report focuses on the time that can be saved by consumers who leverage AI.

Spin that around a little to make “smart AI” work for you.

For example, you may have any number of incoming referral faxes. They need to be read and understood. Who are the patients? Why are they being referred? From whom is the referral coming? Then, you have to search your database to see if they exist. For those that do, the faxes need to be digitally attached to the correct records. For new patients, new records need to be created and then have the faxes attached.

Next, you’ll want to call those patients ASAP to schedule their appointments vs. waiting for them to call you.

With smart AI, you won’t have to do any of that. Faxes are auto-read/auto-understood as they arrive. Your database is searched with records identified if they exist and then with the faxes auto-attaching to them, all in nanoseconds. New patients? Those records are auto-created with faxes being attached. You’re alerted to them in the process.

Then, because it’s really smart AI, your scheduler is integrated into the mix, and human-sounding bots, in any language, call patients, identify themselves as calling from your practice, and then can schedule appointments. Back-and-forth exchanges can happen until a good date/time is arrived at with the patient. It’s so seamless that the patient may not realize they’re speaking with a bot.

There’s more: the system should automatically get immediate eligibility verifications, have a prior authorization option that gets them automatically when needed, and can produce out-of-network alerts.

Everything you just read can happen with zero human intervention and without hands-on work.

(Lloyd’s Banking Group was onto something in their survey, which can be seen by clicking here.

ADSRCM and ADS are onto something with our platform and options for automating your incoming faxes, and then all of the ancillary tasks to be done!)

Healthcare Fraud of the Month

A rheumatologist in TX was sentenced to ten years over a scheme that bilked over $118 million in false claims with payments to him of over $28 million for falsely diagnosing patients with chronic illnesses for tests/treatments those patients didn’t need.

The doctor was also ordered to forfeit that $28 million, which included assets comprised of 13 real estate properties, a jet, and a Maserati.

Click here for the details from the US Department of Justice.

The Disparity and Variables in Charity Care

There’s no uniformity in charity care, especially when it comes to hospitals. Depending on where they seek medical help, those who need charity care may end up “on the hook” for medical expenses.

In a recent report by the Lown Institute, charity care policies at 2,500 hospitals across the country were reviewed. It showed that there is little to no federal standard for charity care eligibility. While hospitals are expected to provide charity care (free or discounted care to patients with low incomes), there’s no federalized way of doing this, which is why often, those patients end up with medical debt.

For example, the report showed that in NYC, a charity-eligible patient could get free care in one hospital but not at another.

The Lown Institute indicates that the problem is derived from a lack of federal or statewide standards for charity care. State or federal policymakers should consider establishing minimum eligibility standards for free or subsidized charity care and certain eligibility checks, such as a uniform application form.

Click here for the Lown Report.

Published: CMS-2567

Two collaborative entities, the Directors, Quality, Safety & Oversight Group (QSOG), and the Survey & Operations Group (SOG), have published CMS-2567: Statement of Deficiencies and Plan of Correction.

It’s all about helping patients receive “straightforward healthcare” so they can make the best decisions about their care. Also, CMS-2567 “aligns with the Nursing Home CMS-2567 process, which, per regulation, is releasable within 14 days of transmission to the facility (See 42 CFR 488.325).”

Side note: the update does not apply to Accrediting Organization (AO) survey findings unless they are “related to surveys of Hospice and Home Health Agencies.” 

Click here for the memo and its details.