The shift from a fee-for-service reimbursement model to a value-based model is a not an easy one for providers, but it’s something more and more organizations will have to contend with in the future. The Centers for Medicare & Medicaid Services (CMS) is driving this shift. According to The Health Care Payment Learning & Action Network (HCPLAN or LAN), their goal is to have close to 100 percent of reimbursements tied to value-based contracts by 2025. So, it’s no surprise that many groups are defining what that transition to value-based care models would look like and identifying challenges that could present themselves. Based on our research, here are the top three challenges you may face as you’re planning for your transition.
1. Operational Overhaul
With the fee-for-service model, providers are paid based on the number of patients they see and procedures they perform. This lends itself to patients only being seen when needed, and doctors trying to fit in as many appointments as possible. The value-based pay structure corresponds to the quality of care patients receive, which means providers need to spend more time with patients to gain a stronger long-term, holistic view of their health.
This increased level of proactive patient care and evaluation requires a new approach. More hours will need to be dedicated to preparation, coordination, and analysis. One study on providers who have about 20% value-based revenue found that more than 80% felt they needed additional staff and hours to manage it. This operational transformation is most likely the biggest challenge organizations face, as it involves a greater global change with additional communication and data insight to be successful.
2. Actionable & Quality Data
With reimbursement based on quality of care, it’s imperative for providers to have easy access to all data and metrics that are important to keeping their patients healthy. However, effectively using and extracting the important data, especially ICD-10/HCC codes, and knowing whether it’s accurate or not can be overwhelming.
An efficient, real-time and actionable data workflow needs to be put in place and continually refined to ensure less time is wasted and the correct information is being served.
3. Keeping Profits Up
Teetering between the two reimbursement models not only requires increased staff and administrative work, but it also lends itself to a less predictable revenue stream. If you’re incorporating the two models, with the same amount of staff and hours, it’s not possible to see the same number of patients and perform the same amount of procedures than in a solely a fee-for-service world. As one physician organization described it, “the administrative complexity of administering these plans is likely to be costly. The unpredictability of the revenue stream is likely going to make administering some of these plans not worth the cost.”
With more work and less predictable revenue coming in, organizations need to be as lean and efficient as possible. They also need to capitalize on all means of reimbursement from their fee-for-service business. Clearly there are many barriers to transitioning to value-based care. But while the challenges may seem daunting, with an effective plan, the right technology, and a good team, anything is possible.
See how RCxRules can help make the value-based reimbursement transition easier by scheduling a 15-minute meeting.
We can help ease challenges with value-based care models by helping your team work smarter, not harder. We work closely with you to create custom rules to meet your organization's unique needs and to ensure coding compliance. We then help you determine which rules can be set up to automatically correct routine billing errors, freeing up your team’s valuable time to focus on more important issues.
RCxRules automated HCC coding software dramatically increases coder productivity by identifying and directing only those high-value encounters with HCC coding gaps to coders for review—all before a claim is submitted.
Wherever you are in the transition to value-based care models, RCxRules can help. We have actionable plans for both financial models that keep your revenue management cycle operations and profits top of mind.
