The healthcare paradigm has shifted. Instead of a reactive model for healthcare reimbursement, successful outcomes are now geared around an episode of care designed to reward providers for managing health, not treating illness. Bundled and other alternative payment models are forcing providers to work together in new ways, in a more coordinated model with the primary care practice as the epicenter of preventative care.
Consumers are being tasked with taking on more payment responsibility, which is causing them to competitively shop for lower costs. Finally, technology is also evolving, allowing consumers unprecedented access to healthcare providers in our more mobile, digital era.
In the thick of all this change, we know that three things will remain constant: higher costs, declining reimbursement and increased government regulation.
While value driven care is still in its infancy, more risk will continue to move toward providers, as traditional fee-for-service reimbursement continues to lessen. As value-based care is heading toward us like a freight train, how has this new reimbursement model affected how we bill and get paid for our work?
It’s About Quality, Not Quantity
Despite the current administration’s best efforts, the Affordable Care Act (ACA) is still the law of the land. This groundbreaking legislation focused providers on quality, access, and affordability. In January 2015, the Obama administration announced their goal of tying 30% of Medicare reimbursements to quality or value; and 50% by 2019.
Last August Becker’s ASC Review reported on the HealthLeaders Media Value-Based Readiness Survey, which found that around 94% of healthcare providers had initiated some form of quality-based care:
- 35% of surveyed providers participated in a value-driven pilot.
- 55% termed their organization as “very strong” in their efforts to adopt value metrics.
- 65% said they had developed collaborative models with payers.
As providers have begun shifting reimbursement models, we’ve seen some of the practical effects of value-based treatment models on coding. Some of the effects have included:
- ICD-10 documentation forced providers to adopt a more specific set of procedure and diagnosis codes. This in turn, affected the revenue cycle. Billing departments had to align codes with the episode of care and payer requirements.
- Increased risks are now tied to quality outcome metrics. The revenue cycle must change to support these initiatives.
- Increasing audits and payer scrutiny necessitate coding workflow changes from the provider to the back office.
- Patients are more active in their care including paying for it. The era of high-deductible insurance is forcing physician providers to compete for patients, who are now more fiscally conscious of their healthcare decisions.
- The new revenue cycle is focused on the patient. Value-based care requires strategy, operations, and customer service to align. Technology, access and care excellence will be the new drivers affecting both patient and provider.
- Data analytics will drive the capture of quality metrics and population health initiatives. As healthcare providers continue to reap the benefits of proactive and preventative treatment modalities, the data and how we use it will become increasingly important to the revenue cycle.
Preparing for the Value Shift
The team at M-Scribe believes the journey to value-based care should focus on three key goals:
- Using state of the art technology to optimize revenue cycle performance by decreasing errors.
- Shifting care delivery models to take advantage of value-based reimbursement.
- Investing in new technologies to increase access and the quality of care.
We can help your team reap the full benefits of the new value-paradigm. From payer contract review and credentialing to medical coding and an A/R audit, our practice is designed to help your practice reap the full benefit of the latest reimbursement models. Call us at 770-666-0470 or by email me at Patrick.Dougherty@m-scribe.com for a free analysis of your practice needs.