The RCxRules Blog

3 Ways to Transition to Value-Based Reimbursement Without Hiring More Staff


While the fee-for-service model of care is based on quantity, value-based programs focus on quality and patient outcomes. Unfortunately, many medical organizations are finding it financially daunting to increase their quality of care and develop relevant infrastructure in order to transition to value-based models. Medical groups are already facing payroll-driven budgetary stresses, as the MGMA 2018 Staff Salary Survey uncovered: 

  • 36% of medical practices feel understaffed
  • 23% had to cut back on benefits to save money
  • 60% of practices are unable to give raises due to decreasing reimbursements by payers and patients

For many medical organizations, going on a hiring spree to meet value-based requirements is simply not an option. Here are three tactics for achieving value-based success on a tight staffing budget:


1. Re-evaluate Staff Roles

Financial success under value-based programs largely depends on accurately identifying and coding the health of your patient population via HCC codes. Ensuring accurate HCC codes throughout the current calendar year is essential to improving risk scores and the overall dollars allocated to treat your patients. But physicians are not coders, and the quality care and optimal patient outcomes that value-based programs demand can be jeopardized if they bear too much of this responsibility. Physicians should be focusing on what they’re trained to do—caring for the health of their patients.

Dr. Gerald Maccioli, Chief Quality Officer of Envision Healthcare, notes that physicians “…are being asked to capture and analyze vast amounts of information and comply with new regulations, all the while continuing to maintain a standard of excellence for quality care and patient safety.” 

Establishing clear and separate roles and responsibilities for physicians, care coordinators, and coders helps all staff members to work more harmoniously and efficiently on pre-visit planning and HCC coding review, which will likely lead to more accurate risk scores. 


2. Train Staff to Capture and Review Relevant, High-Quality Data

The vast amount of data required to manage value-based care and contracts can be overwhelming, making it crucial to quickly focus on and prioritize the data that matters—that is, the data that’s needed for optimal financial as well as clinical outcomes.

According to Dr. Maccioli, “value-based care is not just about capturing data to meet requirements. It's about ensuring we're capturing the right data and analyzing it in a way that drives continuous quality improvement, increased efficiencies, and cost savings.” 

As noted earlier, ensuring that accurate HCC codes are captured in the current calendar year will contribute to the improvement of risk scores and the overall dollars allocated to treat your patients. To make that happen, it’s important that staff be trained to not only aid in the physician’s capture of the HCC data with best front-end practices, but to also assist in the data review to ensure the accuracy and completeness of the coding before claims are submitted and risk scores are established. To aid in the HCC coding process, savvy organizations are making investments in coder education focused on clinical coding accuracy. 

National Quality Forum Senior Director Jason Goldwater points out that “All the measures in the world aren’t going to matter if you have horrible data… It’s not simply having the ability to report on a certain number of measures. The focus needs to be on where the data is coming from for these measures and how good that data is… It doesn’t come down to just choosing the measures you think are the most appropriate—it comes down to having the reliable data for these measures to give a better indication of quality.” 

If your staff is educated on how to help collect the right data to ensure that complete and correct diagnoses are documented, your risk scores are far more likely to accurately reflect the health of your patient population—leading to appropriate reimbursements to care for that group.


3. Use Automation Technology to Increase Staff Productivity

Far too many operations continue to rely excessively on manual processes to chase down errors and mistakes resulting from bad or incorrect data. This wasteful activity requires an enormous amount of rework and expense, and healthcare organizations must realize that the status quo is no longer good enough. Lean process management—which focuses on eliminating or reducing waste associated with activities that consume resources without adding value—is a great way to tackle this problem.

Lean Principles, Clean Data and Your Business OfficeThe key is automation, which can: 

  • Drive consistency and compliance with industry standards (such as HCC coding methodologies)
  • Help maintain internal best practices and specific payer contract considerations
  • Automate up to 75% of the coding/billing review process

The ROI is clear—empower your team to work on high-value tasks—such as documentation review for a Medicare Advantage patient with multiple chronic conditions—rather than manually skimming through all patients to find the “needles in a haystack.” 

For more tips on successfully managing the value-based transition, check out our on-demand webinar—HCC Coding: Best Practices to Improve Capture Rates—and improve your risk scores for more accurate reimbursements.  

Watch On-Demand Webinar: HCC Coding- Best Practices to Improve Capture Rates Now!


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