Medicare Reimbursement Denied – 5 Essentials for Succeeding in the New World of Healthcare

One of the many challenges doctors are facing this year is the transition from volume-based to value-based pay. Medicare Access and CHIP Re-authorization Act, also known as MACRA, replaces the current Medicare fee-for-benefit reimbursement plan with a new values-based care framework that focuses on quality, value and accountability. This transformation is the most important industry-wide effort that will affect millions of healthcare providers across the country.

MACRA offers two reimbursement path models, Advance Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). The MIPS model is an incentive model that consolidates three existing Medicare quality programs into one. Many independent physician practices will choose MIPS for the incentive-based benefits and potential to increase net sales through payment adjustments, which in some cases reward value in primary care rather than volume.

In the face of such dramatic changes, independent medical practices are asking: what can we do to thrive under this new values-based care equation?

In this article, I share some tips to help individual and small healthcare practices make better use of information technology tools in the context of value-based care. In addition, we are looking at how we can improve financial results while reducing overall costs.

5 tips for the success of small independent practices

1. Robust investment in analytics to predict resumes.

By understanding the patterns in your data, you can act on trends before they become costly problems.

For example, by analyzing data information about treated patients. Small practices can more easily flag patients who are likely candidates for readmission. Then tailor patient engagements and interactions specifically for those patients. From there, make the quality improvements that can lead to better clinical outcomes. The cost of investing in a population health management solution can help deliver greater savings over time.

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Remember, the only way to report on these results—and get paid for the services you provide—is with high-quality data. Look for an IT solution like a population health management system to provide the high quality data you need.

2. Empower patients to take control of their own health

Independent health practices should focus on the specific characteristics of their communities to approach a quality-driven model. Strategies that personalize care and empower patients to take better control of their own health are most promising.

For example, a physician who serves a predominantly Hispanic population might consider developing diabetes prevention programs. These programs could focus on curbing the spread of the disease.

Developing such programs can help small independent practices to better define information technology tools. For example, data-driven tools. These tools provide insight into cost and quality metrics, providing the data needed to make care decisions consistent with effective clinical practice. This can improve service delivery and better value-based outcomes.

3. Provide continuous access to business-critical systems and data

Regardless of the size of your business, no business can afford downtime. In healthcare, system failures cost more than money. They can cost lives. When the flow of data is disrupted, the impact is viral, impacting patient health and safety, internal processes and revenue.

High availability is no longer a nice-to-have, but a must. In all industries, high availability (HA) is measured in nines. “One nine” refers to 90% system uptime, “five nines”, a standard reference value, refers to 99.999% uptime. Downtime that occurs during peak patient care hours impacts your business more than downtime that occurs outside of peak hours.

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For high-availability configurations, your IT must ensure that data flow is uninterrupted and that patient and administrative functions are running to standards. High availability for healthcare should:

  • Allow for planned system maintenance and upgrades without service disruption

  • Respond to unplanned system outages

  • Scale to meet your volume needs

  • Reduce the strain on your internal IT resources

  • Use fault tolerance and automatic error detection

  • Offer 99.999% Uptime

Individual and small medical practices that have traditionally viewed downtime as an inevitable or necessary evil must adapt to the increasing demands for availability. As the volume of information exchange increases, so does the revenue lost per second of downtime.

4. Form alliances to meet requirements and maximize payments

A great way to maximize payments under the CMS payment policy is to forge an alliance with other healthcare organizations. The right alliance can help meet the needs of payers and patients for quality delivery.

Given the central role technology plays in today’s healthcare environment, you should carefully consider the IT implications of a new alliance before committing to a partnership. Considerations that may be helpful in ensuring a successful clinical partnership include:

Embrace sharing – Many organizations have disparate technologies that need to work together. Invest in integration platforms that can connect almost seamlessly and streamline and simplify information sharing.

Insist on interoperability. Many organizations have invested in EHR or EMR technology. Forcing allies to change technologies for consistency only creates more confusion and disruption. Implementing an integration model that allows meaningful use of information across clinical systems will increase interoperability.

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5. Back up your data

Health data is the new frontier for aggressive hackers looking for an easier and more lucrative way to carry out identity theft. The estimated cost of a healthcare breach is $200 per patient record. This does not include lost business and financial resources. The security of your applications, patient data and your system will help maximize your payments under CMS.

When it comes to health data, you can never be too sure of the facts. Here are steps you can take now to better protect your data:

  • Recognize that policy changes need to come from the top levels of an organization

  • Assess the 5 Rs in your security strategy: risk, redundancy, replication, recovery, and accountability.

  • Review and update your HIPAA compliance regularly. By achieving HIPAA compliance, you also improve your cybersecurity posture.

With declining reimbursements and the shift to value-based care, standalone and independent healthcare providers face ever-increasing pressure to reduce healthcare costs. In order to protect margins, business processes must be managed more efficiently

Value-Based Nursing Equation

The holy grail to achieving optimal value-based care is finding more cost-effective ways to deliver optimal care in a more cost-effective environment that is also accessible. To thrive in the age of value-based compensation, small independent healthcare organizations need tools to measure their outcomes.