Providing better care while reducing costs is no easy feat and ensuring profitability along the way requires strategic change. Many organizations seeking to embrace a value-based approach tend to focus first and foremost on transforming clinical initiatives—but the business side is just as important to long-term, value-based success.
Establishing a timely and effective HCC coding review process is crucial to making sure your patients' RAF scores are aligned with your high-quality care. Accurate RAF scores ensure proper funding from payers to allow for the continuation of care for those patients, and the continual sustainability of a value-based model. For one clinic in Indiana, putting their focus on reimbursements made all of the difference in achieving their goals.
With a bold commitment to improve care while reducing costs, The South Bend Clinic initially invested in clinically oriented tools at the beginning of their value-based care journey, including population health software, EMR optimization, and more. Despite making great strides with clinical initiatives, it quickly became apparent that there was a missing factor in The South Bend Clinic’s value-based care equation.
RAF scores did not match up to the population they were treating—in reality, patients were sicker than the scores suggested. In order to achieve their mission, The South Bend Clinic needed to find a way to close their financial gaps by ensuring more accurate RAF scores.
By teaming up with RCxRules, The South Bend Clinic was able to accurately and efficiently correct the misalignment between RAF scores and their patient population. In a matter of weeks, they put technology to work to uncover missing HCCs, increasing RAF scores by 34%. But the progress didn’t stop there.
In less than two months, their HCC coder captured an additional $504,220 in RAF value. The power of automating HCC coding review allowed the team to review more HCCs in less time and with less resources, and according to CEO Kelly Macken-Marble, the organization was “easily able to scale up with value-based contracts.” Mission accomplished.
While this may seem like a one-of-a-kind success story, it’s possible for any healthcare organization to implement the same strategies as The South Bend Clinic to maximize value-based profitability with minimal investment. We’ve broken down how here.
Learn from The South Bend Clinic with these 4 steps for success:
1. Put the right teams (and tools) in place:
Having the right people and the right tools in place made all of the difference for The South Bend Clinic’s RAF-score accuracy undertaking. With the support of RCxRules HCC Coding Software, they were able to appoint a single coder to take charge and concurrently review value-based encounters. Establishing a focused point-person, equipped with automated and efficiency-increasing software, set the stage for a fast-track to success.
2. Mind your gaps:
To get started, The South Bend Clinic put their RCxRules software to work to automatically review every encounter finalized in their EMR. By evaluating each HCC encounter pre-claim, they were able to accurately pinpoint coding gaps and instantly identify opportunities to increase RAF scores.
3. Focus on high-value encounters:
When RCxRules’ software flagged HCC coding gaps, The South Bend Clinic’s coder was free to focus on the most high-value encounters to ensure no details slipped through the cracks. This strategy allowed them to increase their average RAF score by 34% where supported documentation was uncovered.
4. Increase real-time visibility:
The South Bend Clinic was able to say goodbye to costly retrospective reviews using RCxRules’ real-time monitoring and reporting capabilities. This improved visibility allowed for increased efficiency and resulted in over $500K of RAF value being identified in less than two months.
For more information about how The South Bend Clinic used RCxRules software to improve their RAF score accuracy, you can check out the full case study here.
