Value-Based Care & Your Revenue Cycle: 8 Moves to Make

MIPS and value-based care are changing reimbursement rules, and the old moves your eye care practice has mastered to coax reimbursement out of payers in the fee-for-service context won’t be the moves you need to profit in the future.

The good news? Skilled coders, billers, and practice administrators are inherently data-driven. We can adapt our existing skills to help our practices thrive under value-based care in the future. So flex your muscles, break a sweat, and master some brand new choreography for your revenue cycle.

Move #1: Choose your quality measures wisely.

Up to now, “pay for quality” reimbursement has been mostly a joke. (I’m talking to you, PQRS and Meaningless Use.) But the high cost of caring for patients with chronic conditions is forcing payers to get serious about coordinated patient care and quality outcomes. And that’s actually good news for revenue cycle teams trying to get buy-in from physicians and clinical staff. No longer must you cajole them to check a box that seems pointless.

If you carefully chose the quality measures your practice reports under MIPS and similar programs, you can directly link your efforts to patient care and outcomes. What ophthalmologist or eye care clinician wouldn’t get excited about the opportunity to add value (and get credit for it) by helping patients manage their diabetes better?

ECPs have over 20 quality measures to choose from in the MIPS ophthalmology measures set. Several of these are either “outcomes” or “high priority” measures—they offer the opportunity to score bonus points. Before choosing your measures, be sure to compare your previous PQRS performance to CMS’ baseline performance benchmarks for those same measures. Choose your measures based on how well you can meet and exceed those baselines.

Move #2: Make sure your clinicians are correctly documenting chronic conditions.

Under fee-for-service, the purpose of a diagnosis is to establish medical necessity. Under MIPS and other value-based care initiatives, it’s much more than that. CMS will use your 2018 Medicare claims history to determine your 2020 reimbursement rates. So what you’re currently documenting and coding not only determines what you get paid right now, but also what you’ll get paid in the future.

The quality and resource use categories are risk adjusted—they take into account that patient outcomes are affected by factors outside of your direct control. Be sure to look closely at the documentation for patients with chronic conditions and make sure you are coding any comorbidity as secondary. Make sure that your claims are using codes to tell the whole story. For instance, if a patient is not being compliant, use codes for patient non-compliance so that you tell that part of the story.

Remember, if you don’t document it, you can’t code it. Accurately and completely documenting chronic conditions and comorbidities may require a mind shift for clinicians as well as coders. “Providers need to be re-triggered to veer away from fee-for-service thinking and become more involved in the complete and accurate documentation of chronic conditions and comorbidities for appropriate and accurate coding,” says Susan Whitney, CPC-I, who spoke about the future of coding and reimbursement at a previous MGMA conference.

Move #3: Measure your practice’s answered call rate compared to timed-out and abandoned call rates.

Revenue integrity starts from the moment the patient calls your practice. Call center snafus can mean empty appointment slots and lost revenue, and they don’t help patient satisfaction scores either. High patient-satisfaction scores are essential to succeed in value-based care.

High timed-out and abandoned call rates can indicate you have nonsensical push-button options in your phone tree, a flawed system, or untrained call center staff who don’t know how to use the system efficiently. Timed-out and abandoned call rates that spike at certain times can mean your call center is understaffed during those times.

The first time you run these kinds of analytics and share them with your staff can be painful, because you are drilling down through gut reactions and anecdotal impressions to get down into the data-driven truth. Sharing these data with staff—without blame—and working together to solve the problems the data reveal will help your practice improve by leaps and bounds.

Move #4: If you have a multi-location site, measure clinic visits per location.

If you have multiple sites, you hear them all clamoring for resources all the time—some more loudly than others. Don’t let the noise win. Everyone thinks they need more staff, so quantify their requests. Any time you run a report, you position yourself to be smarter about resource allocation so that each location has just the right staffing level it needs to ace patient engagement and thrive amidst value-based care measures.

Move #5: Measure gross charges billed per month.

If you discern a revenue dip and you didn’t have physicians on vacation during that time, you may have a scheduling or posting problem.

Move #6: Check reimbursement levels for the codes you bill most often.

If you also collect 100 percent of your billed charges, you should consider whether your fees are too low.

Move #7: Reconsider how and when you measure A/R aging.

Accounts receivable is the outstanding money owned to your practice. The longer the account goes unpaid, the higher the days in A/R. Some practices have A/R aging goals of 20 percent overall or less, which means they can pull in the revenue by the 120-day mark and still make goal.

Don’t set the bar so low for A/R aging that you cost your practice money. Eye care practices don’t see a lot of trauma, so you can usually set your A/R aging goals at 28 days or less.

The moment you begin to see the days in A/R metric creep up, you must search for the root cause. Make sure that your RCM staff is looking at acknowledgement reports to understand which claims aren’t making it past the scrubber. Make sure that they are solving those problems instead of simply hitting ‘submit’ over and over again without results.

Tip: If you use your system’s default aging report, the “days in A/R” may reset if the balance owed is transferred from one party to another (say, from a payer to the patient). This can conceal the true number of days in A/R.

Move #8: Use data to view your RCM team’s work objectively.

Then, coach them accordingly to improve procedures. Data is objective, so try to intentionally incorporate data analysis into your revenue cycle routine. That helps stop the finger pointing and get to the root of problems that stymie your success under value-based care.

For example, you might look at your charge entry timelines as a measure of your RCM team’s efficiency. Charge entry for office visits should happen within 24-48 hours. Charges for surgeries can take up to 72 hours because of dictation time. How long is it actually taking your RCM team to post charges?