Here's what RCM leaders should be doing to tackle this pervasive pain point
Payer denials are, to put it mildly, a pain. In this week’s The Winning Edge webinar on defeating denials, WVU Medicine’s Beth Carlson lays out the groundwork for an effective—and forward-thinking—denials management strategy.
The long-awaited proposal for a special registration would help providers with virtual treatment programs for addiction and behavioral health concerns. Critics, however, say the proposed rule isn't what they hoped it would be.
Healthcare providers will finally get a special registration to dispense controlled drugs via telemedicine, a kay part of virtual care treatment for patients in substance abuse and behavioral health treatment.
But the proposed rule, unveiled Wednesday by the U.S. Drug Enforcement Administration (DEA) and expected to be published on Friday, isn’t necessarily sitting well with telehealth advocates.
The proposed rule creates three tiers of providers who could prescribe controlled drugs. The first tier comprises clinicians wanting to prescribe Schedule III-V level drugs; the second would apply to specialists, such as pediatricians, psychiatrists and those in hospice or palliative care, who want to prescribe Schedule II drugs. The third tier would comprise clinicians wishing to prescribe Schedule II-V medications via telemedicine and would require that they register with the DEA through Form 224S.
“The rise of DTC online telemedicine platforms in recent years has further transformed healthcare delivery, but it has also introduced new challenges and heightened risks of diversion due to the remote nature of care delivery,” the DEA noted. “The proposed registration requirements for telemedicine-based prescribing and dispensing create a new business activity within DEA’s overarching registration framework, distinguishing it from the traditional modes of dispensing under a 21 U.S.C. 823(g) registration.”
Among the restrictions included in the proposed policy: Providers wishing to prescribe controlled medications via telemedicine must be located physically in the same state as their patients, and they must issue at least half of their prescriptions after in-person appointments.
In addition, providers seeking a special registration to virtually prescribe controlled substances must check prescription drug monitoring databases in all 50 states and U.S. territories (the one exception is buprenorphine, or Suboxone, for which providers would only have to check the database in the state where the patient is located). That provision would take effect three years after the proposed rule becomes law.
The DEA announcement comes after the agency extended a pandemic-era waiver three times that allowed providers to prescribe via telemedicine, and comes 17 years after the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 mandated that the agency create a special registration process.
Telehealth advocates, led by the American Telemedicine Association, and several lawmakers have criticized the DEA’s efforts for years, first for ignoring the mandate to create a special registration, then for proposing mandates that they say are restrictive or convoluted.
“It is clear that these updates carry significant implications for the telehealth community,” Kyle Zebley, the ATA’s senior vice president of public policy and executive director of the organization’s lobbying arm, ATA Action, said in a press release. “Early indications suggest the proposed rule includes elements that represent significant operational challenges. All stakeholders need time to carefully review this important proposal, which appears to incorporate valuable elements and other potentially unworkable restrictions that focus on maintaining compliance with patient verification, electronic recordkeeping, and ongoing monitoring.”
“We are pleased to see the DEA propose a special registration, as required by statute, to allow comprehensive medical care through telemedicine, including Schedule II medications,” the Alliance for Connected Care said in a release issued shortly after the DEA’s notice of proposed rulemaking. “These treatments are important in providing mental health, end-of-life care, substance use treatment, and many other services. Telemedicine has proven to be an effective tool in bridging the gap between patients and providers, reducing barriers to care, and supporting those most in need.”
“However, the alliance is very concerned to see language in the proposed rulemaking mandating what portion of patient care can be offered through telemedicine, as this is not an appropriate guardrail for a telehealth service,” the organization continued. “Similarly, restricting the geography in which telemedicine can be offered undermines the value of creating virtual access for those patients who need it most. Restricting access to telemedicine will lead to harsh consequences for many Americans relying on telehealth for mental health, substance use disorder, sleep disorders, terminal illness, and many other medical issues.”
The Foley & Lardner law firm, whose Telemedicine & Digital Health Industry team has long monitored the quest for a special registration, also panned the new proposal.
“The DEA published these rules, not because they were fully ready for implementation, but to ensure they were not abandoned by the incoming Trump administration,” Marika Miller, a telehealth and regulatory attorney with the firm, told STAT News. “The long-awaited special registration process falls flat with stakeholders, and it is anticipated that the associated rule will undergo yet another round of notice-and-comment rulemaking. Among other concerns, a key issue for stakeholders with both rules is the nationwide prescription drug monitoring program check requirement, a burden the DEA still appears to underestimate.”
The proposed rule, which will now face public comments through March 15, isn’t guaranteed. The incoming Trump Administration, which hasn’t yet named someone to lead the DEA, could drop or ignore the rule, reinstating the policy in place prior to the COVID-19 pandemic.
In HealthLeaders' latest The Winning Edge webinar, WVU Medicine’s Beth Carlson explains how revenue cycle management leaders can improve denials management to not only prompt better and quicker resolutions, but reduce denials before they even occur.
Denials are a key pain point for revenue cycle leaders, and a problem that affects the entire organization, from patients on through to providers. But today’s RCM executives don’t have to go it alone in addressing this problem.
Through collaboration with other departments, such as clinical, and the use of technology like AI, RCM leaders can move upstream and proactively address denials even before they occur. They can also better prepare for when denials do occur, and work with payers to understand and improve the process, reducing expensive and time-consuming appeals and ensuring that patients receive the care they need.
In this week’s HealthLeaders The Winning Edge webinar for defeating denials, Beth Carlson, VP of Revenue Cycle at WVU Medicine, explains how today’s RCM departments aren’t just a back-office function of the healthcare enterprise, and that they’re much more involved in helping patients get the care they need by addressing and improving denials.
To fully embrace this strategy, Carlson offers three pieces of advice:
Establish a Strong Denials Management Process. Create a framework not only for addressing denials, she says, but also understanding why they happen and how they might be avoided. Study payers to understand when and why they issue denials, even spotting trends with certain payers and delaying tactics; work with providers to examine medical necessity and care pathways, helping them to understand when a certain procedure or process might go against a payer’s policies; and even work with patients so that they understand their benefits and options for care.
When denials do occur, start with a root cause analysis to understand all the factors of that particular denial, and be ready to to establish a “triage escalation capability” if a denial is particularly complex. Make sure service lines—clinical, financial, legal—review them as well, so that everyone understands why they happened.
Collaboration is Key. RCM can’t happen in a vacuum any more, Carlson says. It’s crucial that RCM leaders work with other departments to both understand denials and address them after they happen.
Working with clinicians will help both RCM staff and clinicians to better understand how denials happen. Clinicians can then develop care pathways for their patients that steer clear of procedures that would be denied by payers, and RCM staff can identify and work with clinicians who cause frequent denials. In addition, there are occasions when a doctor can prove to RCM leaders and even a payer that a certain policy isn’t working, and can help to have that payer change the policy to reduce denials.
Looping in the legal department is important as well. They can help RCM leaders develop strategies to speed up the denial resolution process, including understanding when a case is too complex to pursue.
And finally, working with patients at the earliest point in the healthcare journey—before the patient even comes into the hospital—can benefit everyone. Educating patients on their financial responsibilities, health plan coverage and other details of the care experience can reduce the chances of an unexpected or surprising cost down the road. This also gives RCM leaders and staff and opportunity to better understand the patient’s care journey, and to work with patients on a care plan that synchs with their insurance coverage and policies and reducing the chances of a denial.
It's All About the Data. As with almost any facet of the healthcare enterprise, data is the key to improved performance and outcomes, and with today’s technology (especially AI), there are many more opportunities to access, manage and find value in data. With denials, this means gathering all the necessary information ahead of time on payers, providers and patients.
Carlson says RCM leaders need to understand the data and how they can use it—and how to use AI tools to get the most out of that information. They can better understand payer policies and trends, identify coding mistakes and opportunities, and gain insight into provider tendencies and care pathways that lead to denials.
That data comes in handy when dealing with payers as well. RCM leaders who are armed with the right information can not only smooth the denial resolution process, but work with payers to identify improvements (in either provider practices or payer policies) that can reduce denials and improve patient care and outcomes.
Are consumers having an 'I'm mad as hell and I'm not going to take it any more' moment?
What’s keeping healthcare innovation executives up at night?
Many challenges. But one of the chief concerns is the potential (or perhaps the threat) of an empowered consumer, armed with their own health data and demanding AI-enabled care at the time and place of their choosing.
Health system executives like Chang, Highmark Health President and CEO David Holmberg and ChristianaCare President and CEO Janice Nevin, MD, MPH, were on hand Wednesday at the CES 2025 Digital Health Summit to gain some insight into the latest in consumer technology, but to understand how that will affect the healthcare industry. And their prime focus was on their patients’ dissatisfaction with the state of healthcare.
“We’ve got to move things forward,” said Holmberg, “and find a way to meet people to treat people where they’re at (and to) treat people as consumers.”
That’s a tough task for a healthcare industry that, Nevin pointed out, “isn’t traditionally very adventurous,” and which has taken decades just to get doctors and nurses on the same page. But the industry as a whole is in crisis, buffeted by workforce shortages, quality and cost concerns and a growing number of disruptors looking to replace the traditional care routine. Healthcare leaders need to recognize the driving forces shaping the industry and adapt to those changes.
CES offers those executives an opportunity to see where consumer technology is headed, and to understand the new ideas that are driving change. Alongside the ever-growing digital health space in the Venetian’s exhibit hall was an even-faster-growing space dedicated to the smart home. Combined, those platforms showcased a future where consumers will have more data on their environment and their health at their disposal, alongside more tools to track, analyze and improve their life journey.
Holmberg, taking note of those new technologies, said healthcare needs to “innovate its way out of” the mess it’s in. That means creating, fostering and embracing scalable tools and technologies that can take healthcare out of the hospital and doctor’s office and into the home.
Healthcare leaders are under pressure to improve the consumer experience, and they’re using tools like virtual care and digital health to improve care delivery. Those tools also aim to improve provider workflows and tackle the ongoing epidemic of stress and burnout that are contributing to declining workforces.
AI will in many cases shape that environment, and it’s being seen as a critical part of the healthcare journey as well—for both consumers and providers. Some see a future where AI could replace the doctor or nurse, while others say the technology will assist providers in making the best use of data.
Nevin, taking note of the healthcare industry’s reluctance to embrace change, said she’s worried “that we’re going to lose this moment in time.” She called on the industry to do a better job at collaborating, sharing ideas and data and knocking down the silos that create care gaps and frustrate consumers.
“We tend to point the finger at each other” she noted, rather than working with each other.
Not everyone agreed on the need for collaboration. Eli Lilly And Co. CIO Diogo Rau noted that competition might be a good thing.
“There has been a lot of collaboration in the industry that has worked against consumers rather than for consumers,” he pointed out, drawing applause from the packed audience. “I want to see more competition there to bring down the cost of medicine and the amount of healthcare.”
When asked about the future of healthcare, Rau envisioned an industry focused more on prevention and wellness that proactively treating diseases. Holberg envisioned an industry able to manage the incredible amounts of data coming in and creating care maps for consumers. And Nevin saw smaller, more focused hospitals, fewer hospital beds and an industry focused on meeting consumers where they want to be met.
But will the industry move fast enough in that direction to placate a growing consumer population—especially seniors and those with chronic care needs—that’s dissatisfied with the current state of care? Will consumers demand change?
At a separate panel on the future of AI that included Chang, Stephen Klasko, a former president and CEO at Thomas Jefferson University and Jefferson Health who’s now an executive in residence with General Catalyst, said he’s surprised that consumers haven’t yet had a “I’m mad as hell and I’m not going to take it any more” moment.
“My car gets better care than I do,” he quipped.
And that’s where AI might move the needle. But the industry has to overcome its concerns and move forward quickly.
Chang, noting the lack of healthcare providers in the audience and at CES in general, said the industry needs to embrace AI, rather than worry about the potential for mistakes or overuse.
“AI can absolutely be the equalizer,” he said. But “it pains me how much resources are being wasted because we’re [looking to solve] the wrong problems.”
“One of the biggest threats that we have is misunderstanding the technology,” added Jake Leach, Dexcom’s Chief Operating Officer.
Laura Adams, RN, a senior advisor for the National Academy of Medicine, part of Kaiser Permanente’s Institute for Health Policy, said the healthcare industry is nearing a tipping point where consumers will have more experience with AI than their doctors and nurses. Healthcare providers need to keep up, she said.
“The revolution is very much underway,” she added.
A CES panel anticipates policy advances for digital health innovation, as providers and politicians look to measure the value of new ideas like AI and telehealth.
At a time when the nation is divided and combative, can digital health bridge that gap and bring both sides together? And could this help healthcare leaders plot a path forward for new ideas like AI, Hospital at Home, and wearables?
The idea was hinted at during a digital health policy panel Tuesday at CES 2025 in Las Vegas. Moderated by Catherine Pugh, the Consumer Technology Association’s Director of Digital Health, the panel tossed about the idea that digital health may have enough support on both sides of the aisle to see some good policy wins during the upcoming four years of the Trump Administration.
“This is a bipartisan issue,” said John Quinn, Legislative Director for the Office of U.S. Rep. David Schweikert (R-Arizona). And there aren’t many of them around.
Quinn, along with panelists Stephanie Fiore, director of Digital Health Policy for Elevance Health, and Susan Kirsh, MD, MPH, Deputy Assistant Under Secretary for Health for the Department of Veteran Affairs’ DEAN portfolio, listed several topics that are likely to play a prominent role in healthcare policy over the next four years, including AI, telehealth, data interoperability, consumer privacy and CMS reimbursement.
The challenge, the panelists said, will be in finding a path between innovation and cost—a key initiative for the incoming administration.
As Fiore noted, “telehealth is a big deal,” but at the same time it’s “an expensive policy.”
AI could be the driving force in this argument. Kirsh, who’s involved with most of the digital health and telehealth strategies followed by the VA—the nation’s largest telehealth network—pointed out that AI has made some significant strides in reducing administrative workflows and reducing stress on clinicians, and is just now being integrated into clinical pathways.
“There is an incredible amount of opportunity in the clinical space,” she said.
The key for health system and hospital CIOs, CTOs, Chief Digital Health Officers and others is a comprehensive policy and standards that allow healthcare leaders to use AI safely and securely, and not be bogged down by administrative details that push clinicians away from the technology.
The same goes for telehealth and digital health. Quinn spoke of the potential of wearables to help both consumers and their care providers monitor health outside the doctor’s office, and Kirsh talked of the advances in augmented and virtual reality that allow clinicians to better experience what their patients are going through and to better prepare new doctors and nurses for the workforce.
The hangup is reimbursement. Clinicians won’t use this technology if they’re not supported by payers, especially Medicare. And the Centers for Medicare & Medicaid Services (CMS) has been slow to advance new reimbursements and permissions because of the cost. Quinn noted both they and the Congressional Budget Office often have a hard time seeing the long-term benefits in health and wellness for those new technologies.
“We need to close the gap with CMS on reimbursements,” he said, “and make innovation legal.”
And for at least the next two years, he added, those agencies will be faced by a Congress controlled by one party in both the House and Senate. In the past, he said, they tend to listen more intently when that happens.
Fiore spoke of the advances in technology giving consumers access to (and more control over) their data. She sees the next four years as a pivotal time for consumer privacy and security policy, and while the federal government has struggled to pass legislation on consumer protections, more and more states are taking action on their level.
Quinn, referencing the recent spate of cybersecurity incidents, especially the Change Healthcare debacle, agreed.
“The unfortunate reality is that data is not private right now.”
And a new administration that prides itself on the strength of the private sector could make that a priority.
Unfortunately, the path ahead for digital health policy isn’t clear-cut. Nothing happening in Washington these days is easy to predict. Quinn noted that many healthcare-related provisions in the original 1,500-page end-of-year budget bill were removed, and that the final, 150-page bill that was passed by Congress contained few healthcare gains.
Researchers found that most health systems following the CMS Acute Hospital Care at Home model are large urban hospitals, and said the current model may not be sustainable for small or rural hospitals.
A new study of the Hospital at Home strategy questions whether it can stand up in rural areas and small hospitals, key markets for the innovative program’s growth and sustainability.
In a December 23 study posted in JAMA, researchers from UCLA and the University of Pennsylvania say almost all of the healthcare organizations participating in the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home (AHCAH) program are large, urban, not-for-profit and academic hospitals.
As of December 2024, 373 hospitals across 139 health systems in 39 states are following that CMS model, which includes a waiver enacted in 2020 to help participating hospitals receive Medicare reimbursement. The waiver was recently extended to March 31, 2025, and with CMS hinting that it will no longer grant extensions, supporters are lobbying Congress to make it permanent.
The implications of this latest study are that only large, well-resourced health systems can sustain a Hospital at Home program, leaving a significant percentage of the nation’s health systems and hospitals out in the cold. Yet advocates say this strategy, while complex, can save money and resources and improve clinical outcomes, all key metrics for any type of hospital.
“If CMS’ goal is to continue to expand hospital-at-home, these findings suggest that different incentives or outreach may be needed for smaller, rural, and non-teaching hospitals,” Hasham Zikry, MD, MS, an emergency medicine physician and clinical research fellow at UCLA Health and lead author of the study, said in a press release.
(One notable exception is Sanford Health, which launched its CMS-approved AHCAH program in November 2024 targeting patients in rural communities around Fargo, North Dakota. The health system is currently targeting an annual daily census of five patients and hopes to bring that number up to 12 soon.)
Zikry and his fellow researchers, David Schriger, MD, of UCLA Health and Austin Kilaru, MD, MSHP, of the University of Pennsylvania’s Perelman School of Medicine, also cite two familiar criticisms of the Hospital at Home movement: That these programs haven’t yet proven their value, and that they don’t take into account the pressure put on patients and their caregivers at home.
“Are family members of these patients acting as unpaid caregivers during these admissions?” Zikry asked in the press release. “Could these patients do just as well in other care settings? Do patients actually prefer to be at home? And are health systems leveraging this program equitably?”
In addition, he said: “Resources are being poured into these programs around the country, yet we still don’t have a comprehensive understanding of how the programs are functioning on the ground.”
Many expect the Hospital at Home strategy to take a hit if Congress declines to extend the CMS waiver or make it permanent. Without Medicare reimbursement and a relaxation of certain telehealth rules, some health systems may end or cut back their programs.
That said, supporters are arguing for at least another extension so that participating health systems can gather the data needed to prove the concept’s value. The prevailing opinion among both supporters and critics is that the strategy needs more time to gather data to prove value.
With its Digital Health Summit, the annual Consumer Electronics Show is giving healthcare leaders a look at the potential for truly integrated care.
As CES 2025 kicks off this week in Las Vegas, healthcare’s innovation and transformation leaders are keeping an eye on the Consumer Technology Association’s (CTA’s) Digital Health Summit, as well as the various consumer-facing technologies, tools, and toys that could play a role in the health system of the future.
Healthcare has long claimed a part of the CES experience, starting with connected devices and apps designed to help consumers manage their health. Over the past several years, though, healthcare executives have joined the party, looking for tools and strategies to bridge the gap between the consumer and the patient.
Rene Quashie, CTA’s Vice President of Digital Health, says the event gives healthcare leaders an opportunity “to explore the future of health tech in the context of a broader, interconnected ecosystem.”
“Unlike traditional health conferences, CES brings together the full spectrum of technology innovators across industries, creating an environment where healthcare solutions are discussed alongside advancements in AI, robotics, IoT, and beyond,” he said in an e-mail to HealthLeaders. “This convergence fuels cross-industry collaboration, helping healthcare leaders identify transformative technologies and adapt them to meet the needs of consumers, clinicians, and payers.”
That integration should continue as health systems and hospitals push more services out of clinical settings and into the home, and as care providers develop programs to track their patients at home and manage care remotely. Strategies like remote patient monitoring (RPM) and Hospital at Home will rely more on consumer-friendly devices as that scale up and build sustainability.
Against that backdrop, there are opportunities for healthcare throughout the CES exhibit halls, which span both the Las Vegas Convention Center and the Venetian Expo. The smart home concept is an intriguing venue, with AI-enabled devices, sensors and appliances that can be used to monitor consumer activity and health, even diet, sleep, behavioral health and bathroom activity. Automobile manufacturers are including health apps and sensors in their new models, and even the popular gaming area includes games and gaming platforms that can be used for healthcare.
Quashie says the theme for healthcare-related events and vendors at CES this year is “the future of health,” with topics including AI, digital therapeutics, genomics, wearables, women’s health and workforce issues.
Will leaders get the answers they need from CES to advance their orginizations? I'll be there to report.
HealthLeaders’ most-read stories of the past year highlighted an interest in virtual care and care management, especially when connected to CMS coverage
The growing market for virtual care dominated HealthLeaders’ most-read innovation stories of 2024.
Coming out of the COVID-19 pandemic, healthcare providers were fighting for the attention of empowered patients/consumers and facing competition from employers looking to control health plan costs and disruptors eyeing the convenient care market. The resulting battle for primary care saw a proliferation of virtual care platforms, giving patients access to primary care at the time and place of their choosing.
2024 saw an expansion of that strategy, with virtual care platforms for specialist consults, chronic care management, remote patient monitoring and other services.
The top story for the past year focused on one of the biggest disruptors in that market, Amazon, which launched Health Condition Programs in January. The online platform matches consumers to relevant health and wellness companies based on their browsing and shopping habits, enabling consumers to create managed care plans based on their health concerns and health plan coverage.
“Amazon wants to make it easier for people to get and stay healthy, and part of that is making it easier to discover the products, services, and professionals that can help them do that,” Aaron Martin, Amazon’s vice president, said in a press release issued by Omada Health, a digital health company that is partnering with Amazon to offer diabetes prevention and care and hypertension care services through the new platform. “Many aren’t aware of the healthcare benefits they are eligible for, that are typically no cost or subsidized by their employer or insurance plan. When customers are shopping for health-related products on Amazon, we can surface these benefits to provide even more support in improving their health, at no additional cost.”
Healthcare providers are bullish on care management as well, and they want to use virtual care and digital health to create those services for their patients. The traditional sticking point has been reimbursement: providers won’t fully embrace new technology unless they’re paid to use it.
The second-most popular story this year was the Centers for Medicare & Medicaid Services’ (CMS) new program to support providers using virtual care and digital health to create value-based care programs. The Advanced Primary Care Management (APCM) model, with HCPCS codes included in the 2025 Physician Fee Schedule, incentivizes clinicians to use technology to create care management pathways around their patients, a key strategy on the journey to value-based care.
“While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing,” Alexandra Shalom, senior counsel with the Foley & Lardner law firm, said in a November blog. “HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.”
The third most-read story veered off in a different direction, though still focusing on the idea that providers are using virtual care and digital health to beef up their patient engagement efforts. A panel session at the HIMSS24 conference and exhibition this past March centered on how smaller health systems and hospitals, struggling to make ends meet and faced with competition, are changing their business model to focus on care management and preventive care, rather than ‘sick care.’
“A great deal of our future is in the outpatient side,” Tressa Springman, SVP and chief information and digital officer at LifeBridge Health, a five-hospital system based in Maryland, said during a panel session.
She noted that more than 50% of the health system’s quality-based reimbursement score for the state is focused on the patient experience, making that more important than actual clinical care. So they’re now setting their sights on access, convenience, and outpatient interactions.
“We’re really focusing on the community,” she said.
The draft and final PFS also gave advocates of digital therapeutics some good news: New HCPCS codes that will enable providers to seek reimbursement for some behavioral health treatments that use FDA-approved devices.
On the other hand, CMS did include some small improvements in telehealth coverage, but also said it wouldn’t extend most pandemic-era waivers to telehealth coverage and access. The news stunned telehealth advocates and led to coordinated lobbying efforts to have Congress extend those waivers. That lobbying will continue into 2025, as Congress only extended those waivers for three months in its year-end, stopgap funding bill.
The fifth most-read story of 2024 centers on perhaps the biggest lesson learned this year in healthcare innovation: Disrupting the status quo to achieve true transformation is hard. This past May Dollar General, the nation’s largest retailer by number of stores, announced that it was ending a two-year partnership with digital health provider DocGo.
The news wasn’t exactly, well, new. Walmart, Walgreens and CVS Health had all recently rolled back their primary and virtual care ambitions, highlighting the challenges that the retail and pharmacy chains were having in cracking the healthcare market. The lesson to be learned, perhaps, is that healthcare isn’t an easy nut to crack, and while new ideas from outside the industry may look great on paper, they aren’t scalable or sustainable.
The stopgap budget bill gave key telehealth and Hospital at Home waivers a three-month reprieve. Supporters now have to convince a fractured Congress and new Administration that these waivers are crucial enough to be made permanent.
Telehealth and digital health policy will remain a hot topic in early 2025. But will three months be enough time to convince a fractious Congress and new Administration of the benefits of permanent coverage?
Telehealth advocates and supporters of the Hospital at Home strategy are celebrating what amounts to a moral victory in the last-minute passage of a stopgap budget bill. The 100-page bill—which originally clocked in at 1,500 pages before it was pared down to make the grade—includes extensions of key telehealth waivers and a continuance for the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home (AHCAH) program.
But those waivers only extend another 90 days—barely enough time to schedule an in-person doctor’s visit--and several other digital health and telehealth provisions were cut.
Supporters are now continuing their full-court press on Congress to make those provisions permanent, something they’ve been working on for several years. They’re hoping the letters to lawmakers signed by hundreds of healthcare organizations and support of dozens (if not hundreds) of House and Senate members will sway Congress.
“We will immediately begin working to ensure Congress makes Medicare telehealth flexibilities and the Acute Hospital Care at Home Program permanent—or secures a much longer extension than 90 days,” Kyle Zebley, senior vice president of public policy for the American Telemedicine Association and executive director of ATA Action, the group’s lobbying arm, said in a press release. “Simultaneously, we will advocate vigorously to reinstate the vital provisions that were left out of this package.”
On one hand, supporters are encouraged by the fact that the telehealth and ACHAH waivers made the cut for the three-month extension—meaning Congress thinks they have enough value to continue. On the other hand, those waivers have been extended before, and the incoming Trump Administration has signaled its interest in cutting costs and reducing administrative clutter. The challenge will be on supporters to push the value in making these waivers permanent.
The final bill includes a 90-day extension (instead of two years, as was in the original bill) on several telehealth flexibilities enacted by CMS during the COVID crisis to expand coverage of and access to telehealth. They include:
Waiving geographic restrictions on telehealth coverage and use;
Expanding the list of providers able to bill Medicare for telehealth services;
Allowing audio-only telehealth services;
Easing originating site restrictions on telehealth so that the patient can receive treatment at home;
Waiving the in-person requirement for telemental health treatment;
Enabling telehealth service for hospice care; and
Enabling Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to use telehealth.
In addition, the bill extends the CMS waiver for its AHCAH program for three months, instead of five years, enabling the more than 350 health systems following the CMS model to receive Medicare reimbursement.
Among the telehealth provisions that were cut out of the final package:
First dollar coverage of High Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs);
Support for virtual care providers in the Medicare Diabetes Prevention Program;
Improved coverage for digital health in home-based cardiology and pulmonary rehab programs; and
The SPEAK Act (HR 6033), which paves the way for accessible telehealth services.
CMS has already said it won’t extend the waivers any more (though the agency did include some telehealth, remote patient monitoring and digital therapeutic improvements in its 2025 Physician Fee Schedule). So it's up to Congress to decide if there's enough value in the waivers to make them permanent.
William Sheahan of MedStar Health, a participant in the HealthLeaders Mastermind program, says healthcare leaders need to look beyond the technology and prepare doctors and nurses for new workflows
AI may truly be a transformative technology, but its integration into clinical care needs to be managed well before the technology is even introduced.
"How do we get our people, our nurses, our doctors, our clinicians, our revenue cycle teams, to understand how the technology supports the future of their work?" asks William Sheahan, SVP and Chief Innovation Officer at MedStar Health and executive director of the MedStar Institute for Innovation. "We can't just focus on deploying the fun new technology and expect that organically it's going to change your business, right?"
Sheahan, a participant in HealthLeaders' Mastermind program on AI in clinical care, says healthcare leaders need to focus on change management as they embrace AI. That means not only working to bring current doctors and nurses up to speed with the technology, but looking to medical schools to make sure the next generation is prepared for an AI-infused workplace.
William Sheahan, SVP and Chief Innovation Officer at MedStar Health and executive director of the MedStar Institute for Innovation. Photo courtesy MedStar Health.
"We have the imperative to swim upstream, into undergraduate medical education, in nursing schools and medical schools, and insert some of this foundational education," he says.
Sheahan says MedStar Health is pursuing an AI strategy that recognizes how the technology will change healthcare delivery, which includes the effect on the provider as well as the patient. As such, the ROI of a new tool or program looks beyond financial costs to include clinical outcomes and provider wellbeing.
That means getting buy-in from all parties, especially clinicians. Sheahan says innovation leads like to participate in town halls with system physicians to introduce new tools like ambient AI, giving them a chance to ask questions and try out the technology before it's added to their toolkit. The idea, he says, is to include clinicians in the planning so that they're invested in the process from the start.
"This isn't forced change," he points out.
Instead, he says, it's organizational change. That's what comes with a holistic technology that is being embraced by consumers as well as clinicians. Organizations that aren't already properly pursuing this in-demand innovation may otherwise be forced to react rather than act with the times.
With national issues like workforce shortages, cost concerns and increased competition for the patient/consumer plaguing the industry, healthcare leaders are challenged to hit the ground running with AI. Sheahan says he, like any other innovation executive, is excited about the potential for AI to improve clinical care, but they still need to plan out the process and understand the outcomes.
That includes understanding how data is gathered, stored and managed, processes that certainly need to be modernized. Health systems and hospitals have long been gathering data without fully understanding its potential uses. AI promises to make the best use of that data if it's guided and governed properly.
While some health systems have created AI committees or even C-suite roles to manage AI, Sheahan says separating AI from other innovative strategies can hinder progress. He's more supportive of integrating AI governance into existing management structures. In many cases, he says, a new AI tool can have multiple benefits across different departments—like an ambient listening tool that not only improves clinician note-taking but helps the rev cycle department improve coding.
"AI as a technology shouldn't be governed entirely differently than other technologies," he says.
As for the future of AI in the clinical space, Sheahan envisions an AI-enabled operating system serving the enterprise, responding to queries from pretty much anyone within the health system. The platform might help doctors map the best care plan for patients, give nurses direction on inpatient care, help the rev cycle management team deal with a prior authorization or denial, or even map out the best route for a patient to a specialist appointment across town.
"We want to show the many groups that can benefit from AI why and how to use it to make themselves more efficient," Sheahan said. "Ultimately, that is what is going to deliver ROI over time. We can make our business more efficient if we're all in this together."
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