Alyshia Ravida

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So far Alyshia Ravida has created 11 blog entries.

AAHAM Applauds Energy & Commerce Committee for unanimously agreeing to send HR 3630 to the House for a vote July, 2019

Fairfax, VA – The American Association of Healthcare Administrative Management (AAHAM), the leading professional association focused exclusively on the healthcare revenue cycle applauds The House Energy & Commerce Committee’s 48-0 vote to send H.R. 3630, the No Surprises Act, to the full House of Representatives for consideration. This legislation seeks to protect patients and families from “surprise” or out-of-network medical bills, which has become a major issue for patients.

“AAHAM applauds Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) for their hard work and willingness to allow all sides to be heard on this complex issue” said AAHAM President, John Currier, CRCE-I. “We want to thank all the members of the Committee for their work by taking the first step towards ensuring patients are protected and there is an independent body who will serve as arbitrator in these types of cases” Currier added.

H.R. 3630 includes a last-minute bi-partisan amendment offered by Representative Raul Ruiz (D-CA) and Representative Larry Bucshon (R-IN), which would allow certain payment disputes between providers and health plans to go to arbitration. The Ruiz-Bucshon amendment would let either side appeal the federal benchmark payment to an arbiter in cases when the median in-network rate paid to doctors or hospitals exceeds $1,250.

“Today Congress took another step forward to ensuring we take the patients out of the billing equation. Thanks to a bi-partisan effort by Rep. Ruiz and Rep. Bucshon, we get closer to creating a billing system that allows for an independent voice to decide the outcome and not a federal benchmark rate, which would likely drive up the cost of healthcare for everyone” said AAHAM 2nd Vice President, Amy Mitchell, CRCE-I.

“Baseball style arbitration works” stated AAHAM Treasurer, Kenny Koerner, CRCE-I. In my home state of Illinois, we have baseball style arbitration and it works. We don’t walk away happy with every outcome, but we know by having an independent voice review the claims of both sides, we have the chance to be heard” he added.

AAHAM will continue to work with all relevant Committee’s in the House and Senate on this critical issue. AAHAM supports patients and bringing healthcare costs down through Baseball style arbitration.
ABOUT AAHAM

AAHAM is a national professional association of thirty-one chapters and over 3000 healthcare revenue cycle professionals from hospitals, clinics, billing offices, allied vendors, physicians and multi physician groups. AAHAM members direct the activities of the thousands of people who are employed in the healthcare industry.

AAHAM is the premier professional organization for revenue cycle professionals and is known for its prestigious certification and educational programs; professional development of its members is one of the primary goals of the association. AAHAM is also recognized for its quarterly journal, The Journal of Healthcare Administrative Management and its Annual National Institute. AAHAM actively represents the interests of its members through a comprehensive program of legislative and regulatory monitoring and participation in industry groups. For more information on AAHAM and its programs, please visit www.aaham.org or contact AAHAM, 703.281.4043.

Pennsylvania Health Insurers Restricted in Retroactively Denying Medical Claims By Chuck Hilton

In November of 2016, the Governor of Pennsylvania signed into law Act 146, which prohibits Pennsylvania health insurers from retroactively denying reimbursement of claims beyond 24 months after such claims were approved for payment, with a few exceptions. Specifically, the law states:

§ 3803 Retroactive denial of Reimbursement.

(a) General Rule – Except as provided in section 3804 (relating to exceptions to retroactive denial of reimbursement), an insurer may not retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date the insurer initially paid the health care provider. An insurer that retroactively denies reimbursement to a health care provider under this chapter shall do so based upon coding guidelines and policies in effect at the time the service subject to the retroactive denial was rendered.

(b) Written Notice – An insurer that retroactively denies reimbursement to a health care provider under section (a) shall provide the health care provider with a written statement specifying the basis for the retroactive denial.

40 Pa.C.S. § 3803

As providers are well aware, insurers often perform audits to determine if previously paid claims were incorrectly paid because the codes on the submitted claims were improper and/or not compensable. As a result of these audits, insurers often scrutinize previously paid claims dating back several or more years. Act 146 limits the insurer’s potential to retroactively request a refund to 24 months after the date the insurer initially paid the providers claim. Accordingly, if a provider receives a refund request from an insurer’s audit alleging “improper coding”, be aware that the insured is limited to request a refund on only those claims paid within 24 months from the date the claim was initially paid. If the claim was initially paid by the insurer more than 24 months from the refund request, Act 146 does not allow the insurer to follow through with its request for a refund. However, Act 146 does have certain exceptions to the limit of a 24 month look back period. For instance, Act 146 restrictions to the look back period do not apply to claims involving waste, fraud, abuse and duplicate claims. In addition, the restrictions to the look back period under Act 146 do not apply to state or federal health plans requesting refunds.

There are a few more subject matters addressed within Act 146 that a provider should be aware of. If any provider has questions or inquiries regarding any portions of Act 146, please feel free to contact Attorney Charles J. Hilton, Charles J. Hilton & Associates, P.C., The Revenue Cycle Law Firm, Oakmont Station 2, 527 Cedar Way, Suite 203, Oakmont, PA 15139, Telephone 412/435-0162, email chilton@cjhiltonlaw.com.

2019 Membership Campaign by Holly Horn, Membership Chair

Chapter membership is vital to the success of any chapter. Three Rivers AAHAM membership entitles a member to a wide range of benefits that include but are not limited to:

 Education – Opportunities to strengthen and improve our knowledge and skills
 Certification – Nationally recognized certification programs to give us the competitive edge in our careers
 Publications – To keep us up to date on happenings in the association and the profession
 Chapter Involvement – Opportunities for peer networking, cutting edge training, education programs and leadership development at the local level
 Discounted registration rates to Three Rivers AAHAM meetings, conferences and webinars
 Scholarship Program – Offers educational scholarships to our members

Three Rivers AAHAM, as well as, National AAHAM offers FREE student membership to full-time students. To qualify as a full-time student member an individual must be currently enrolled in a semester with a minimum of 12 credit hours. Student members receive all the benefits of membership except for voting, eligibility for the national scholarship and eligibility for professional certification (CRCE, CRCP, CRIP). If you know a student in the healthcare arena, refer them to AAHAM so they too can take advantage of the excellent programming and networking opportunities our organization offers.

Our membership dues for 2019 are $30. If you have not already done so, take a moment to renew your Three Rivers AAHAM membership today.

If you have any questions regarding AAHAM membership, contact Holly Horn, Three Rivers AAHAM Membership Chair or Brenda Fraas, Chapter President.

Educational Event Scholarship Program

PURPOSE
In continuation of our stated purpose and objective of furthering the education and increasing the knowledge of our membership in the healthcare industry, our Scholarship Program provides educational scholarships to Three Rivers Chapter provider members to attend AAHAM conferences.

Note: Provider member shall be defined as an individual currently employed by an entity that provides health services to healthcare consumers.

AWARDS
As available funds permit, scholarships in the form of one (1) paid registration fee associated with a local Three Rivers AAHAM conference OR a National AAHAM Conference event.

FUNDING THE SCHOLARSHIPS
Fundraising events will be held at Chapter meetings, the goal and desire of which is to raise sufficient monies to fund as many scholarships as feasible per year.

SCHOLARSHIP COMMITTEE
The Three Rivers Scholarship Committee will be responsible for overseeing the administration of the scholarship program to include directing related fundraising activities, receiving scholarship applications, and making recommendations to the Board for award selections. The Scholarship Committee shall be comprised of the Chair of the Board who shall serve as Committee Chair, the President and the Treasurer.

SELECTION
Applicants who meet the established criteria will be considered for selection by the Scholarship Committee who will make a recommendation to the Board. Selection will be based on a review of the application and the evidence of financial eligibility.

Note: Financial eligibility may be defined as expenses for conference attendance not being fully reimbursed by the applicant’s employer.

ELIGIBILITY
Any healthcare provider member of Three Rivers Chapter for at least one year and participated in a minimum of one (1) chapter meeting in the previous or current calendar year

QUALIFICATIONS
1. Must meet financial eligibility as above defined.

2. Non-financial considerations such as applicant’s attendance, participation, and assistance in Chapter activities will be considered as well.

APPLICATION
A completed Member Event Scholarship Application should be submitted to the Chair of the Board at least 60 days prior to the event the member wishes to attend, but no earlier than 90 days prior to the event.

FORFEITURE OF AWARD
The Scholarship awardee is expected to attend and participate in all education sessions and events during the conference. In addition, the awardee is required to submit a summary of the event detailing how the event impacted his/her individual career. Failure to do so will result in consideration of future scholarship opportunities.

AWARD LIMITATION
No member may receive more than one award per calendar year.

NOTIFICATION
The Board of Directors will approve all final selections of a Scholarship recipients. Award recipients will be notified within 45 days of the event that applications were received for.

Legislative Day 2019 by Ken Krieger, Legislative Chair

This years annual Legislative Day was held April 15-16 at the Hyatt Regency on Capitol Hill in Washington, DC. About 90 AAHAM members from across the country attended this year, including 13 from Pennsylvania and 5 from our Three Rivers Chapter. Our State, and particularly our Chapter, were well-represented as usual, thanks to first-timers Rick Fries, Beth Hoover and Christine Ifft along with Kathy Sandora and me. This was my 13th (out of 15th) visit yet it doesn’t get old, as each year has its own flavor and personality.

For 2019, our charge was – and still is with ongoing communication/follow-up – making Congress much more aware of the issue of Price Transparency. Past issues like the TCPA and 340-B were revisited, too, since they still matter and are in queue for additional legislation.

Between the five of us, we were able to meet with Legislative Aides from both of our Senators’ offices, as well as Aides, from four different House members. Below is a carve out from AAHAM’S official position paper that we used as a guide and a leave-behind:

Current Initiatives: Initiatives to make charge and price data available to the public are emerging on several fronts. Currently, 42 states already report information on charges or payment rates and make that information available to the public. Last spring, for each hospital accepting Medicare patients, the CMS posted on its website average hospital specific charges per patient and average Medicare payments for the most common diagnosis-related groups (DRG) as well as 30 ambulatory procedures. The ACA requires hospitals to report annually and make public a list of hospital charges for items and services, though CMS has yet to release guidelines for the implementation of this provision.

Recommendations: AAHAM is committed to doing everything possible to better serve patients and to treat them equitably, with dignity, compassion and respect, from the bedside to the billing office. However, we cannot do this without the help of the insurance carriers. As mentioned above, we believe what people want is their total out-of-pocket costs for their care after their insurance payment is made. This is why we need to have insurance carriers at the table for this conversation. Insurers should be required to participate in providing better education to their members about out-of-network or non-covered charges according to their benefit plans.

Visit the National AAHAM website for the full paper and stay tuned to our Three Rivers site for updates on this topic, as well as regular postings on national and state legislative issues that affect both Provider and Vendor Partner members. Anyone is, of course, welcome to reach me directly with questions and comments and/or to get involved.

Alternative Payment Models in Healthcare – “Pick Your Poison” by Nick Campano

Today’s hospitals and providers continue to thrive on traditional, fee for service (FFS) models are challenged with new reimbursement models. These changes will make significant changes in the way healthcare systems conduct their business and care for their patients.

“Branding” among providers and increasing pressure from public and commercial payers to lower costs and improve care are driving them away from long-standing fee for service models, and toward so-called “value-based care” models. These new payment models seek to more fully align payment and objective measures of clinical quality. The question is when you sign on and address the “elephant in the room” that the fee for service ultimately didn’t cover their cost to keep the lights on but new models will be high risk.

Keep in mind the new payment models cannot be separated from changes in patient care delivery; thus, they require increasingly tight hospital-physician alignment. That is easier said than done with various physician employment affiliations, different EHR’s, and willingness to make the changes necessary to support value-based care. As much as healthcare wasn’t satisfied with fee for service; the new proposals are intimidating.

The industry change is a byproduct of FFS rewarding for volume and intensity of service. The more admissions, testing, procedures; the more that provider are reimbursed. The concept that has gone on for more that 30 years is proclaimed to reason as to why health care costs have sky-rocketed.
In the early 2000’s, the concept of “pay for performance” (P4P) emerged as a more popular tactic for aligning provider payment with value. Under the typical P4P model, financial incentives or disincentives are tied to measured performance; they may also involve performance thresholds, improvement thresholds, or relative performance cut-offs. The provider organization receives performance-based adjustments to its FFS rates, usually bonuses for exceeding standards in a particular metric, and occasionally penalizes for falling short.

The P4P model requires less integration and information technology (IT) infrastructure than do other more advanced models, making this model popular among smaller, or newer provider organizations. However, inmost cases, the model requires the abilities to establish clinical quality benchmarks, as well as to collect, measure, and report results. P4P models are a fundamental stepping stone to more advanced forms of value-based care.

The P4P model is not perfect. Often the incentives are too small to change physician behavior, or the patient population being affected is too small to institutionalize change. It also remains essentially a FFS model with respect to “rewards,” with providers receiving higher payments in return for rendering more service.

In summary, hospitals, providers, are in the midst of navigating significant changes in how they conduct business and deliver care and compliment that with new payment alternatives. Healthcare reform and reimbursement will change and how palatable is that to their system is a question. Will they be challenged with their mission and values? Finally, what is their financial exposure?

At the end of the day: “pick your poison” and take advantage of the “best” value-based model for your organization. Good luck!

2019 Spring Conference – What You Missed! by Christine Ifft, Education Chair

Thank you to all that attended our annual Spring Meeting!Our meeting was held at Noah’s Event Center in Cranberry Township on Friday, May 3rd, 2019. The turnout was amazing! Our Spring Meeting usually only consists of payer updates, but this year we threw in a few different presentations.

We started the morning with a continental breakfast, followed by opening remarks and updates given by our Chapter President, Brenda Fraas. Next on the agenda was payer updates from CCBH (Community Care Behavioral Health) presented by Kim Casciato. After a quick break, we reconvened and got a great update from the Hospital andHealthsystem Association of Pennsylvania (HAP) presented by Jolene Calla. Our last presenter before our lunchbreak was Tom Walsh from PNC Healthcare who presented on a current hot topic – Blockchain Technology and how it relates to healthcare. After lunch and networking, we gathered back to hear updates from Novitas Solutions by Diane Hess. AmeriHealth-Caritas was next on the agenda with updates given by Robin Milanak. Christine Ifft then gave a presentation on AAHAM Certifications – what they are, why you should get certified and how it all works. We had a drawing for our 50/50 which was won by Roy Engle from Team Recovery. Roy generously donated his half back to our Chapter which will be used towards the Scholarship Fund! Thank you Roy!! Several attendees won various gift cards from our drawing for completing meeting surveys.

We would like to extend a big thank you to all of our presenters for taking time out of their busy day to provide us with updates. It is always great to hear the latest updates from our payers which also allows us the opportunity to ask our questions.All of the speakers were very accommodating with the questions that were asked. If you are a Three Rivers AAHAM member and were unable to attend the meeting and would like to review the content provided, or if you were in attendance and would like to refer to any of the presentations (We went Green!! No handouts!!), you can find the presentations under the Member’s Only Section on our Three Rivers AAHAM website at www.threeriversaaham.com. Also noteworthy, while we usually participate in the Scouting for Food Drive held in April, we still decided to ask for donations to benefit area food banks. We offered our annual Buy One/Get One Free Registration for all provider members when
they donated a food item. Thank you to everyone who helped us support those in need!

Hope to see you at our Fall Conference at the beautiful Nemacolin Resort in September! Stay tuned for more information!