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How to Succeed in Value-based Care with Service-Enabled TechnologyBy: Burke Burnett, Sr. Director of Product Strategy, Vatica Health With this new approach to care, it’s important for PCPs to understand the impact that risk adjustment and quality of care has on value-based care performance and assess whether their organization has the building blocks in place to ensure success. Unfortunately, PCPs are frequently impeded by insufficient time, data, and staffing resources, which prevents them from reaching their clinical and financial goals under these emerging payment systems. However, PCPs who address these gaps by evaluating their practices’ strengths, opportunities, and partnership needs are well-positioned to thrive in value-based care. Risk Adjustment and Quality of CareAs we move to value-based care, providers will be compensated based on efficiently delivering better results—not more procedures. Value-based care is designed to incentivize providers to improve outcomes in a cost-efficient manner. In other words, payment and quality of care are inextricably linked.Two critical components to any value-based care arrangement are risk adjustment and quality reporting. This is because success in value-based care depends on accurately assessing the clinical needs of your population, and reporting these needs so that your payments will be sufficient to deliver appropriate care. The challenge is that risk adjustment and quality reporting is labor intensive and is predicated on a complex set of rules, which frequently becomes a stumbling block for practices. Because of the complex payment methodology associated with risk adjustment, appropriate coding specificity is needed to accurately report chronic conditions. Without this specificity, plans and PCPs may end up with artificially low patient risk scores, resulting in insufficient funds to deliver adequate levels of care. Similarly, PCPs must adhere to the reporting standards for quality gap closures, and deviation can result in sub-standard outcomes. For practices that lack specialized coding and quality technology, as well as properly trained staff, keeping up with these activities is a significant challenge. What to Look for in Service-Enabled TechnologyMore often than not, PCPs attempt to solve these challenges with the aid of technology. However, as many PCPs know, the implementation of new software can create more problems than it was intended to solve. With office staff burnout at an all-time high, it is important to make sure that any new tools being utilized are supporting, not hindering, the team’s success.What should PCPs be looking for when selecting the right partner? Let us look at some common quality reporting and risk adjustment challenges and how your technology should address them. Provider Documentation Support Challenge: Due to lack of coding expertise and ineffective technology, provider documentation is often not specific enough to support the ICD-10 coding necessary to accurately risk adjust a patient. Many common chronic conditions, such as major depressive disorder, specified arrhythmias, staged chronic kidney disease, and others, can only be risk adjusted when specified in physician documentation. Solution: This level of detail can be achieved with a combination of clinical decision support, computer-assisted diagnostic coding technology, and supplemental clinical staff. Because technology alone cannot eliminate these challenges, augmenting existing staff with clinical resources to supplement these technology solutions, commonly known as service-enabled technology, is emerging as a gold standard. Coding Expertise Challenge: Risk adjustment payment methodology is highly complex. While PCPs may have medical coders on staff, they often lack the specialized skills needed to code to appropriate specificity. To bridge this gap, health plans deploy vendors to perform either home assessments or retrospective chart reviews, which can cause patient and provider abrasion. Solution: PCPs can avoid these pitfalls with EMR-integrated technology that is powered by algorithms that do the heavy lifting by surfacing the most specific and relevant codes. Because an accurate and complete data set for each patient is critical, providers should consider supplemental clinical staff to support provider documentation with the EMR to synthesize it with health plan data. Seamless Quality Reporting Challenge: Quality of care programs can be challenging for providers in value-based care arrangements. Providers often lack the data and tools to support the reporting and activities associated with these measures. Solution: Providers should consider solutions that specialize in quality reporting to foster greater communication and collaboration with health plans. New service-enabled technology solutions change the way health plans and providers are working together to improve financial and clinical results. In a nutshell, technology alone is insufficient. Providers need both powerful EMR-integrated technology wrapped with clinical and administrative support to drive superior value-based care performance. PCPs do not need another application to log into—they need a team of experts behind the screen helping the technology work for them. | About the Author Burke Burnett Burke Burnett is Sr. Director of Product Strategy at Vatica Health. He’s spent the last 10 years designing technology-enabled services for providers, payers, and patients. Burke is a certified coder and risk adjustment practitioner who lives in Dallas, TX with his 3 children. He can be reached via email at bburnett@vaticahealth.com. |
Are Providers Ready for the Post-Covid Audit Challenges Ahead?By: Justin Sanders, Manager of Payor Engagement, Sharecare
In short, for providers that had to scramble to implement new policies, practices, and technology during the pandemic, auditors aren’t going to let you catch your breath as, unfortunately for many, was evident during the 2021 HEDIS season. New Telehealth Audits UnderwayIn February of 2021, the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) announced that it is conducting seven different audits, evaluations, and inspections of telehealth services. These audits will focus on telehealth usage by home health agencies and in Medicare and Medicaid populations. Given that most providers expanded their telehealth capabilities during the pandemic, many providers can expect their Medicare or Medicaid billing relating to telehealth to be subject to OIG scrutiny. How to start climbing the audit mountain?Proactive planning is essential. Typically, this planning starts with creating a task force, which usually consists of your audit teams, your business office, and your HIM department. In smaller practices, these roles may all be the same staff member or one of the providers. This can create challenges when the focus on patient care is diverted, and the provider stops practicing at the top of their license. Your plan should allow you to check all the boxes that take you through a stepwise approach to compliance that includes effective communication with the auditor, Health Plan and other intermediary organizations, closing any information siloes in your organization, documenting and checking for compliance with all audit requirements and ensuring all information is sent in a timely fashion to avoid the risk of monetary penalties. There are strict procedures and timelines to follow, and the auditor may issue follow-up requests, demanding more time and attention. Year-Round AuditsIt’s an unfortunate fact of healthcare practice today: audits are a continuing threat year-round. While some audit types, such as HEDIS, are seasonal, other types are ongoing throughout the years. Likewise, some audits are routine, some are random, and others occur in response to suspected problems. Having a plan to proactively support and respond to audits is an important first step, With audits an ever-present possibility, it makes sense to outsource a permanent solution. Just like you wouldn’t have your internists and nurse practitioners clearing snow with shovels and plows (you’d contract out for snow removal), it doesn’t make sense to divert providers’ time and energy to audit compliance. Often the best option is an audit outsource partner, like Sharecare Provider solutions which allow providers to focus on what they do best: caring for their patients.
| About the Author Justin Sanders Justin Sanders is the Manager of Payor Engagement at Sharecare. He assists with national business development and works with payors and healthcare organizations. Justin develops and fosters strategic partnerships to support the needs of Sharecare’s clients, particularly as it relates to medical chart audits and retrieval. He graduated from the University of North Florida with a Bachelor of Science in Healthcare Administration and enjoys free diving in his spare time. |
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