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How Value-Based Care Has Changed Revenue Cycle Management

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As the transition from fee-for-service to fee-for-value gains momentum, its impacts on revenue cycle management are seen with greater clarity.

Value-based care wields significant potential advantages for patients, providers and payers. But achieving and sustaining fee-for-value success relies on technology and human resources that promote interoperability.

Healthcare organizations’ ability to flourish into the value-based future will rest on their ability to effectively exchange and draw context from electronic health information promptly and purposefully.

The Value of Reconsidering RCM

A number of factors have conspired in recent years to spur providers to rethink their revenue cycle management (RCM) strategies.

Every RCM process has been affected in some way by the COVID-19 pandemic, the healthcare labor crisis, the adoption of value-based care standards, and the integration of policies to adhere to the Centers for Medicare and Medicaid Services Interoperability and Patient Access rule. The fee-for-value disruption is significant because it means that collections from value-based contracts will comprise a larger proportion of provider revenue than traditional service-based contracts moving forward.

Yet the fundamentals of effective revenue cycle management remain — minimize claim denials and maximize the volume and speed of reimbursements.

A recent case study published by the Healthcare Financial Management Association examined the potential revenue pros and cons of value-based care for oncology practices. The study found that high-performing practices experienced payment increases of 19 percent and above.

The HFMA report further identified four key areas in which to optimize revenue cycle management based on fee-for-value care:

  • Value-based forecasting: Revenue cycle forecasting has long relied on past volume and metrics that track the amount and rate of reimbursements. Value-based forecasting requires a forward-looking approach at numerous care-centered benchmarks.
  • Multiple care settings: Providers must account for care across several settings, not just their in-facility visits. This is a domain in which data standardization and consistent, accurate medical coding are instrumental to proper and prompt reimbursement.
  • Risk reduction: Revenue cycle management has long emphasized claim-denial reduction, but clinical and financial risk mitigation must also be front-of-mind when it comes to value-based care. Healthcare organizations need to do more than track denials and evaluate causes; they must assess clinical issues such as deviations in care, errors in outcome documentation and tracking of comorbidities.
  • Real-time adjustments: Value-based care programs are bound in part by performance periods, and RCM leaders have fewer opportunities in a value-based climate to address challenges that contribute to revenue loss. Ongoing revenue cycle evaluations backed by responsive, data-driven tactics are vital to surviving in the era of fee-for-value care.

An end-to-end RCM solution can help providers clear the operational hurdles of value-based care. It can also bestow new, actionable insights that allow providers to reach their financial potential while raising the bar on patient care.

The Value of Data

The fee-for-value shift has heightened the importance of data and quality analytics.

In fact, fee-for-value care hinges on analytics. Value-based reimbursement models are built on metrics related to care quality, formats known as merit-based incentive payment systems (MIPS) and alternative payment models (APMs).

From a revenue cycle perspective, modern health IT can process mass volumes of data in real-time, and that information can be leveraged to make confident decisions on many fronts. Data and analytics are crucial to building a healthy revenue cycle, developing a comprehensive risk adjustment plan and enhancing care quality.

Organizations with value-based contracts must demonstrate their quality of care and cost-effectiveness across diverse metrics. This change aligns with new reporting requirements, but it also presents opportunities to refine productivity, patient care and revenue cycle management.

A recent Healthcare Finance article detailed the benefits of analytics particular to providers who are transitioning to fee-for-value, maintaining a mix of fee-for-value and fee-for-service, or carrying risk-based contracts. Even basic metrics related to patient readmission rates, departmental workflows and follow-up care allow organizations to identify risks and inefficiencies and make knowledge-driven decisions to resolve potential hazards, improve the patient experience and achieve revenue growth.

Value-based care collects multiple data points, the primary function of which is to track the patient journey and evaluate the worth of care. But that data also fuels the drive toward interoperability, and its insights extend from individual patient care to provider and payer profitability to public health.

The Value of Timely Information

The trend toward value-based care is occurring as providers and payers adapt to the Centers for Medicare and Medicaid Services’ Interoperability and Patient Access rule. The moves go hand-in-hand when it comes to information sharing.

For example, fee-for-value care necessitates timely patient data, and the interoperability rule requires healthcare plans to give providers access to updated patient lists. The immediacy and accessibility of this information prevent data silos and stagnation, and it improves the accuracy of claims.

Artificial intelligence can help fulfill the promise of this new wealth of data. AI-enabled health IT systems can use real-time information in conjunction with historical data to generate predictive analytics about resource management, health equity and other concerns.

Accurate, shareable, real-time data streamlines claim workflow, reduces claim denials and accelerates reimbursement. Viable, value-based service and interoperability are attainable with the help of a fully integrated RCM solution.

Value-Based Care and End-to-End RCM

As more providers move to fee-for-value models and strive for interoperability, it’s critical for administrative and clinical systems to share and allow access to data. A fully integrated RCM solution is not just a step toward interoperability and value-based service, but a leap.

A recent MedCity News article outlined key functions an RCM system should offer in a value-based care environment, including:

  • Digital, pre-visit patient data collection: The online capture of demographic information and insurance details before the patient’s appointment.
  • Utilization review: An automated step that matches a patient’s payer information and coverage details with the recommended treatment.
  • Co-pay collection: The collection of the patient’s co-pay based on insurance data and the course of treatment.
  • Medical coding compliance: Accurate coding is essential to proper and punctual reimbursement. Modern RCM systems have pre-loaded code templates and automation capabilities that help ensure accurate claim submission to payers.
  • Reporting and analytics tools: Customizable and deep reporting tools can demonstrate how providers improve health outcomes to qualify for better reimbursement rates, among other insights.

Effective RCM deployment is already indispensable for many providers, and its value will only grow as more practices implement value-based care.

About GeBBS Healthcare Solutions

GeBBS Healthcare Solutions is dedicated to helping healthcare providers, and payers establish interoperability through scalable, comprehensive revenue cycle management and health information management services.

A leader in healthcare technology and third-party human resources, GeBBS has earned acclaim for leading-edge solutions that deliver measurable results for its partners. GeBBS is recognized as one of Modern Healthcare’s Top 10 Largest Revenue Cycle Management Firms, Black Book Market Research’s Top 20 RCM Outstanding Services and Inc. 5000’s Fastest-Growing Private Companies in the United States.

Connect with GeBBS today at gebbs.com to schedule a consultation and learn how we can help you optimize your RCM strategy.

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