5 Ways to Get Paid Under Value-Based Payment Models

Under value-based payment models, physicians don’t necessarily generate more revenue by seeing more patients or performing additional services. This is a stark contrast from fee-for-service payment models under which there’s a direct correlation between volume and revenue. Now, payers increasingly reward high-quality services that improve outcomes. They penalize providers for duplication and inefficiencies that drive up costs. 

“The goal of all value-based programs is to provide the best possible care at the lowest cost,” says Aimee Heckman, CBP, CPPM, a healthcare business consultant who has more than 25 years of experience in medical practice management, revenue cycle management, practice management/EHR implementation, and business development. This is true regardless of whether the value-based program stems from the Centers for Medicare & Medicaid Services (CMS) or commercial payers, she adds.

Is there anything physicians can do to ensure accurate reimbursement in this new era of value-based payments? Yes, says Heckman. And the sooner they prepare and take action, the better, she adds. Here are five strategies:

1. Consider Joining an ACO

“Joining an Accountable Care Organization (ACO) is not the big bad wolf that it has been perceived to be in the past,” says Heckman. “If the practice doesn’t have someone who has the time and ability to stay up to date on value-based payment reform, then joining an ACO can have real benefits. The ACO can provide guidance on what to do to prepare for the value-based payments.”

In addition, a next generation ACOis considered an advanced alternative payment model (APM) under Medicare payment reform. If the practice joins an advanced APM in 2018, it could earn a 5% incentive payment in 2020.

2. Close the Loop on Referrals

“If you send a patient to a specialist, make sure you get the report back,” says Heckman. These reports help physicians determine the best course of treatment for patients. They also help reduce duplication that can drive up the cost of care and negatively affect physician payments under CMS’ Merit-based Incentive Payment System (MIPS), she adds. 

Closing the referral loop is also a MIPS quality measure. This measure captures the percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.

3. Provide Chronic Care Management 

Practices that perform chronic care management (CCM) not only generate additional revenue (an average of $42.84 per patient per month for the first 20 minutes of CCM), but they also help patients manage their chronic conditions, potentially avoiding costly complications and hospitalizations, all of which bodes well under MIPS. 

4. Provide Transitional Care Management 

Practices that perform transitional care management (TCM) also generate additional revenue (an average of $167.04 per patient per month) and potentially help patients avoid readmissions, keeping costs down as well.

5. Code All Complications and Comorbidities

“These are what drive risk adjustment,” says Heckman. Too often, physicians only bill one diagnosis code to get the claim paid, she adds. However, diagnosis codes are what drive payment under value-based models. When physicians identify, evaluate, monitor, and treat a condition—especially a chronic condition—they need to document their work and ensure that the diagnosis is on the claim, she says. Doing so supports risk adjustment and also helps justify medical decision-making for evaluation and management levels.

Best practice is to review all diagnoses on the patient’s active problem list at every encounter, says Heckman. Are these conditions still active, and do any of them require attention? “This is one of the easiest ways to start getting used to the type of documentation you need for value-based payments,” she adds.

Focus on diagnoses that are already included in MIPS quality reporting, such as arthritis, asthma, chronic obstructive pulmonary disease, dementia, depression, diabetes, heart disease, high blood pressure, and others. These are the diagnoses that tend to drive up costs, says Heckman. Many of these diagnoses also have value under commercial risk-adjusted payment methodologies.

Ask this question: Are you following standards of care for these diagnoses as well as documenting and coding all relevant complications and comorbidities? The EHR may include preventive health reminders and other standards of care prompts to help physicians address these diagnoses proactively, says Heckman.

About the Author

Lisa A. Eramo, BA, MA is a freelance writer specializing in health information management, medical coding, and regulatory topics. She began her healthcare career as a...

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