New RCM Strategies for Value-Based Reimbursement

Value-Based Reimbursement

As revenue cycle professionals, we’ve spent so much time in the fee-for-service (FFS) arena that making the shift to value-based reimbursement almost seems too abrupt for many practices, many of which have adapted slowly to the upcoming changes. However, use of the value-based modifier is already upon us, and the Merit-Based Incentive Payment System (MIPS) is taking aim at FFS.

What this means for eye care practices is much more than simply adapting to new computer and claims processes. In reality, if you fail to completely adapt to value-based reimbursement, you could soon find your cash flow in the hole.

Keep in mind, however, that you don’t have to be a technological wizard to implement many of the changes required for the shift. One easy way to adapt is to look at your revenue cycle in terms of an “old way” and a “new way” of doing things. It’s a good idea to begin transitioning to the new way now, if you haven’t already, to ensure that you aren’t behind the eight ball as the coming changes take effect.

So what are you waiting for? Scrap the old way of revenue cycle management, cue up, and take a shot at adopting these practices to keep income flowing:

Confusion Over Patient Coverage

Old Way

Many practices still operate using the “old way” of insurance verification — filing the claim and hoping for the best. Most practices in this situation aren’t deliberately avoiding pre-verifications, it’s just that they’re so swamped with other priorities that they haven’t yet put the wheels in motion to upgrade to a better way of doing things. However, as the first line of defense against denied claims, this is an area where it’s critical for practices to shift to a better way of doing things.

New Way

Front desk and checkout staff must be empowered to know what to collect from the patient up-front, because it costs practices $10 or $15 (including staff time) to send out a statement after receiving payment from the insurer and determining the patient’s portion.

So many patients today have high-deductible or high-copay plans, that it’s essential for practices to configure their practice management software to calculate the allowable so the staff can collect it on the day of service.

Always have your staff members confirm insurance information at the time the patient makes an appointment, and then contact the insurer to get information about the patient’s benefits. That way, you can have all systems in place when the patient presents for the visit. In fact, some practices go further—they won’t even schedule an appointment until the patient’s insurance information is in-hand.

You’ll also want to ensure that your staff has the capability to quickly determine patient balances while the patient is on-site. If it takes a small investment up-front, it’s probably worth it to spend the money on technology that will allow you to interface with your clearinghouse to find out in real-time what the patient’s portion of the charge will be and collect that before the patient leaves. It’s amazing, but only about half of the practices out there are routinely checking eligibility prior to patient services, which is unacceptable because it really just comes down to the click of a button.

Ultimately, this will simplify the lives of your revenue cycle staff immeasurably, but it can be a challenge to configure at first. However, once you complete the burden of putting the data in, you’ve saved yourself time and money in the end.

Coding and Billing

Old Way

In the past, many coders simply trusted the ICD-10 and CPT® codes that the doctor wrote on the superbills and submitted those codes to payers. Under value-based reimbursement, it becomes much more important to double-check whether any chronic conditions or important modifiers accompany the claim, and whether ICD-10 codes are at the highest level of specificity (laterality, anyone?). Simply passing along the doctor’s code selection won’t be enough anymore.

New Way

Reporting chronic conditions and supporting diagnoses are essential under value-based reimbursement, because these will begin to impact your payments in a way they never have in the past.

Currently, practices are assigning diagnosis codes that match what’s on the payer policy, but they aren’t necessarily adding chronic condition diagnoses if they don’t directly support the CPT® code they are billing. The problem with that is we’re not capturing all we need in our claims to make the right payment decisions, so in two years when government insurers make payment decisions on these programs, if we haven’t submitted good claims data we may miss the boat on payments and we’ll have to wait another two years to get the right data in there and get the value from it.

We have to go back to making sure we catch the really granular specifics of family history, concomitant diagnoses and everything we learned in our ICD-10 training to support medical necessity. Quality of care is now more important than ever — if you weren’t listening carefully during ICD-10 training a few years ago, now is the time to start enacting those practices.

Accounts Receivable

Old Way

Eye care providers of the past often made it a practice to hire front-desk staff whom everyone loved, whether or not the staffer knew how to handle accounts receivable. Although it is important to have a likeable person as the “face” of your office, that’s not enough anymore.

New Way

Your front desk staff is your first line of defense in collecting copays and deductibles, so if you don’t have someone at reception who can handle this task, your A/R could be in trouble. Find a front desk person who is approachable but not too timid to ask patents for money and you’ll be on the way to better collections rates.

Collections Practices

Old Way

A decade or so ago, many practices had policies dicatating that they should write off patient balances below a certain threshold, such as $15. But writing off that many charges will impact your practice significantly over time, and could end up costing thousands over the course of a year.

New Way

Make sure you have a good policy up-front so patients are aware of your collections procedures from the beginning. Many insurers will allow you to charge administrative fees like for no-shows or for not paying balances on time, and it’s good practice to consider implementing these charges and putting information about them in your financial policy—as long as you’re fair and consistent across the board with all patients.

Some consultants will tell you that you can have patients sign forms saying that if their insurer doesn’t pay within a certain timeframe—such as 90 days—then the patient is responsible for the charges. If you say that to a patient, you’ve most likely breached the relevant payer contract. You can’t charge someone because you didn’t bill correctly in the first place. Plus, Medicare can terminate your contract if you do that. What you can say is that if the patient fails to provide the practice with correct insurance information, there is a charge to refile the claim.

What you’re trying to combat is the practice of patients giving you the wrong insurance information, and a policy like this can protect you from getting bad data from the beginning. Tell patients about your policy up-front and then they’re more apt to hand you the card every time. Keep in mind that this is only possible if your staff has been trained properly. For instance, if you don’t do appointment confirmations, it would be unfair to charge patients a no-show fee.  

The Bottom Line

It’s your practice’s responsibility to be completely prepared for value-based reimbursement, and it’s clear that living in the past won’t get you very far from a payment perspective. Begin to upgrade your processes now so you don’t find yourself short on reimbursement in the future.

How Will Your EHR Adapt?

Although vendors are adapting, most EHRs and practice management software were designed for FFS. But the value-based revenue cycle is much more complicated, says Ron Sterling, who spoke about potential value-based revenue cycle problems at AAO 2017. There is a good chance that your system doesn’t have a tried-and-true way of posting value-based payments.

For example, if you participate in MIPS, you’ll be spending a full year meeting those MIPS requirements. If you’re due a bonus, you won’t get that money until much later, after the data collection period and data reporting period are over. Once you get that money, what will you do with it? If you’re subject to a penalty, where will the money come from? Most practices haven’t yet thought this through, says Sterling.

If yours is a group practice, and you’re participating in MIPS as a group, Sterling recommends internally tracking each physician’s participation. Then, if you receive a bonus, it will be easier to determine how to allot that money based on who is participating and how much. You need a policy in place that spells out how you are going to distribute MIPS bonuses and penalties, recommends Sterling.

It’s a good idea to speak with your vendor—or attend their user group meeting, if they have one—to discuss equipping your software system for value-based reimbursement. Ask about how your workflows, charge codes, payment and adjustment codes, and charge/service matching will be affected by the shift to value-based reimbursement.

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