Primary Care – Strategies to Improve Reimbursement in the Value-based Care System

by | Published on Jan 10, 2017 | Medical Billing

Primary Care
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Many changes have affected primary care physicians (PCPs) in recent times. These include the shift to value-based care from the fee-for-service payment model, new regulatory requirements, the rise of new models of care, and the merging of independent practices with healthcare systems. While cost-effective medical billing services are available to help with error-free claim submission to optimize reimbursement, experts say that practices will need to adopt new strategies to improve care delivery, stay relevant, and succeed.

A recently published article in Medical Economics discusses some of the ways that PCPs should consider to align their practices to the changing environment.

  • Perform a thorough practice audit: Performing a thorough audit will give practices a good idea of their strengths and weaknesses. The assessment should cover patient population health, finances, staffing, and office procedures. One common issue is increasing overhead costs due to additional staff for in-house medical billing, insurance verification and preauthorizations and government directives. Outsourcing could help as established medical billing companies provide these services at cost-effective rates.
  • Prepare for the Medicare Access and CHIP Reauthorization Act (MACRA) and other healthcare trends: PCPs should familiarize themselves with MACRA, the new payment and quality reporting framework that the U.S. Centers for Medicare and Medicaid Services (CMS) plans to implement. Under the new system, CMS proposes to use performance data collected in 2017 to make payment adjustments for 2019. Practices that have not implemented electronic health records (EHRs) will need to do so to meet the reporting requirements of this program.
  • Improve patient compliance: Under MACRA, 85% of total Medicare payments will be based on value of care. However, for PCPs, the major issue is poor patient compliance. Even the best treatment program such as insulin therapy will be compromised if patients fail to adhere to it. Therefore, PCPs will have to devise new strategies to encourage patients to participate more actively in their healthcare.
  • Improve patient data collection and analysis: Measuring the patient experiences is critical to understand and improve the quality of care. Collecting and reporting patient information can leverage patients’ experiences as well as provide substantial benefits for primary care practices and the healthcare system. To enhance practice income, PCPs will need to evaluate all the measures for which they report data and carefully choose and report metrics in high performance areas.

In addition to this, it is crucial for PCPs to ensure accurate coding and clinical documentation to maximize claim payments in 2017. In the Medicare Physician Fee Schedule (MPFS) proposed rule, there are changes to chronic care management coding and related MPFS payment policies this year. These include three new codes to describe services provided as part of the psychiatric collaborative care model and one code to address behavioral health integration. Moreover, PCPs will need to change the way they document to support admission and level-of-care decisions. Clinical documentation with the patient record should now reflect patient consent and the development of a comprehensive care plan and its availability to the patient and to anyone within the practice or outside the practice, as appropriate.

Changing technology and the transition toward value-based care are inevitable. The future of primary care, say experts, is also likely to involve prolonged interactions among the many stakeholders – PCPs, specialists, politicians, CMS, private insurers and healthcare systems. Experienced medical coding companies that also provide medical billing services can help PCPs manage their administrative tasks and workflows and achieve efficiency under the new value-based care system. Finally, since their reimbursements will be tied to patient outcomes and costs, PCPs will need to monitor the cost and quality of the care delivered by the other members on the team.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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