Medical Billing Expertise for Success in Value Based Payment Models

by | Published on Jul 10, 2017 | Medical Billing

Payment Models
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The tide of health care revenue cycle management (RCM) is changing with the switch to value-based reimbursement. Physicians can benefit from the support of an expert medical billing service provider as they gear up to participate in various value-based initiatives to improve practice performance and raise revenues.

To qualify for a positive or neutral payment adjustment affecting their 2019 Medicare Part B payments, physicians participating in MIPS will need to send data to Medicare beginning January 1, 2018 and no later than March 31, 2018. This will help them avoid up to a 4% negative payment adjustment in 2019.

According to a recent report in Medical Economics, pay-for-performance initiatives such as the Merit-based Incentive Payment System (MIPS) and population health initiatives are based on variables such as cost, patient outcomes, and quality of care which can change during the course of an episode of care. The main RCM challenges that practices face in this scenario are:

  • As revenue is linked to outcomes in both these programs, there is a lot of uncertainty as to how Medicare and private insurance companies will analyze performance metrics and determine payments.
  • Raising the performance of a physician’s practice requires investments in skills and technology.
  • Practices that are not equipped to maintain knowledge about the latest state, federal and carrier requirements face risks of compliance deficits that could impact revenue and cash flow.
  • Hiring professional in-house staff to meet performance measures will be expensive and can lead to a decrease in revenue.
  • Unlike the fee-for-service system, the pay-for-performance makes it difficult to predict revenues.
  • As practices implement the quality-based reimbursement models and other new programs, they will need to improve efficiency in the following areas:
    • data capture, patient registration and pre-registration
    • engaging patients with patient portals, mobile apps and other technology
    • claim submissions, remittance processing, medical coding, and patient collections
    • tracking progress of population care initiatives

All these elements have made the overall RCM process very complicated. Moreover, higher deductibles for insured patients have poses payment collection problems. There are several ways practices can improve their performance in the quality-based payment environment:

  • Take steps to reduce costs of care: Physicians should be well aware of the factors that could increase costs such as the number of visits in an episode of care, the number and types of procedures, drugs and devices used, and how costs could be cut or eliminated by improving processes or systems.
  • Improve patient engagement: Practice staff needs to be trained in customer service techniques. Professional staff can educate and communicate with patients about the management of their chronic conditions between routine visits. Building a team-based approach to patient care is also critical. Both patients and their care givers should be involved in decision making.
  • Enhance patient access: Proper medical appointment scheduling will improve patients’ ability to obtain appointments at times convenient for them. This can reduce emergency room visits and visits to urgent care clinics.
  • Leverage technology: Patient portals will improve communication with patients. Clinical and claims data can be used to identify patients with chronic conditions and to find those at high risk, which will facilitate earlier intervention.
  • Improve clinical documentation: Conducting medical coding and documentation reviews is necessary to report quality of care and associated outcomes for proper reimbursement under the quality based payment models.

Partnering with a medical billing expert will make it easier for practices to achieve these goals. RCM management is a multi-step process. Outsourcing the task to an experienced provider will ensure that everything is taken care of from patient enrollment and patient eligibility verification to charge capture, billing and coding, claim submission, and collections. Teams in experienced medical billing and coding companies work on advanced RCM software and are knowledgeable about all payer requirements and state and federal regulations. They can help physicians leverage their practice systems and take part in the new value-based initiatives to drive overall performance and increase revenues.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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