As we look back at 2019, the seeds of active and emerging healthcare industry trends begin to come into sharper focus for 2020. Many of the articles forecasting 2020 trends for the healthcare market read more like predictions from fortune-tellers — so vague and obvious that they cannot possibly be incorrect, but also so vague and obvious that they provide the reader no value.

We’d like to take a different approach. What we attempt to do here is dive beneath the superficial talking points and instead, provide our take on less discussed trends that we are observing directly from the trenches. Providing a more focused analysis of digital health and healthcare IT future trends is risky — we could get a few wrong — but we think it’s a more interesting undertaking. We plan to revisit our projections next year in July and December to grade ourselves on how well we did.

1. New CPT codes will spur new entrants into telehealth and population health

The release of new CPT codes by the Centers for Medicare & Medicaid Services (CMS) covering remote patient monitoring (RPM) stands to unleash a new wave of entrants into the telehealth and population health space. Specifically, new CPT codes 99453, 99454, and 99457 that allow for reimbursement of initial remote patient monitoring treatment and setup, and CPT 99458 which covers additional time to remotely monitor patients, will smooth the way for new telehealth services since they will now be covered, at least for the Medicare population.

Surgical practices will likely be the early adopters of these codes as they seek to more closely monitor pre-op and post-op patients. Uptake will still remain somewhat muted until the commercial payers begin to reimburse for the new RPM CPT codes.

As a corollary to the use of the new RPM codes, the removal in 2020 of reimbursement for ongoing nursing supervision for home infusion may drive more home Infusion services to be provided remotely, leveraging telemedicine where appropriate, as a means to lower costs.

2. Auto-adjudication of prior authorizations will gain ground

Payers and pharmacy benefit managers (PBMs) are under increasing pressure from physician and revenue cycle groups to standardize the requirements and processes for submitting and adjudicating a prior authorization. The American Medical Association and MGMA are leading the charge at the national and state levels to drive legislative and regulatory changes. Most of the push by these organizations lacks collaboration with health plans and benefits managers, however. Without the proposal of a solution that is mutually beneficial to the interests of both the healthcare providers and payers, the likelihood of a solution to the problem will be slim in 2020.

Without consensus between healthcare organizations and payers, the industry will turn to technology to be the arbiter between both parties. Technology vendors, like Myndshft, have the ability to automate the prior authorization process by using the data that already exists in the healthcare provider’s EHR, combined with the provider’s contracted payer rules. The technology can use the existing data to determine when a prior authorization is needed and automatically submit it, along with any supporting information, based on the payer’s rules. On the payer or benefits manager side, the technology can review each prior authorization submission against medical necessity or utilization management and auto-adjudicate claims that meet the criteria, without human intervention.

Leveraging technology for the auto-submission and auto-adjudication of prior authorization also has the added benefit of reducing redundant data entry for the provider. It also provides an electronic audit trail that helps to prevent waste, fraud, and abuse.

3. Transcription technology will become smarter and more seamless between applications

Latest generation transcription tools — like Amazon Transcribe, Suki, and Robin Healthcare — will build on the healthcare foundation established by Nuance and M*Modal to begin seamlessly integrating into existing workflows, to eliminate data entry burdens for providers.

This will provide the starting point for a frictionless provider experience. These new tools will offer the ability to write discrete clinical data elements derived from the conversation between doctor and patient directly into the EHR, thereby freeing up the doctor to focus more intently on patient care and health outcomes rather than data entry.

4. Increased Pharma interest in real-time medical benefits investigation

An increased number of newer drugs hitting the market must be infused and require administration under the care of a trained physician or nurse. These infused medications require that it be covered under medical CPT codes.

In light of this, specialty pharmacies providing infusion services will need to incorporate real-time benefits investigation for the patient’s medical benefits, determination of patient financial responsibility, and prior authorization requirements beyond the pharmacy benefits.

5. Increased recovery and enforcement efforts by CMS

Increasing regulations and legislation from CMS, especially for hospitals, health systems, and Medicare Advantage providers, will drive the need for improved coding accuracy and cleaner claims.

Diagnostics and genomics labs, in particular, will be pressured to operate more efficiently to meet increasingly stringent PAMA requirements.  This includes the new stipulation as part of PAMA that CMS put a hold on reimbursement for labs testing patients with a family history risk factors.

With the implementation of the CMS CY2019 Home Infusion transitional payment final rule,  home infusion providers will see a loss of reimbursement for care provided when services are delivered remotely, including performing assessments, care planning, and coordination. This threatens to slow the pace of growth in the home infusion market and motivate providers to reduce healthcare costs by using technology to automate many of the processes being performed outside of the patient’s home.

About Myndshft:

Myndshft’s software-as-a-service utilizes artificial intelligence and blockchain to automate and simplify time-consuming healthcare administrative tasks associated with prior authorization, eligibility, and benefits verification, and patient financial responsibility, freeing providers and payers to concentrate more fully on patient care. Myndshft was founded in 2018, and works with leading providers, payers, and health information exchanges. For more information, visit myndshft.com.