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Is Value Based Care Just Regulatory and Reimbursement Hoop Jumping?

Posted on September 17, 2018 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In theory, we all love the move to value based care. Why aren’t we paying healthcare providers to improve care. It just makes sense. In fact, the fee for service model in many ways feels so unnatural. While the theoretical value based care sounds good, getting there is much easier said than done. Translating the simple idea of value based care into regulations and reimbursement is a really hard thing to do.

I’ve often asked the question, “Is value based care just a regulation and reimbursement hoop jumping activity?” Does he who can jump through the hoops the best win? Or is it really the person who improves the care the most win?

I found two Twitter threads discussing ACOs that may shed some insight into not only ACOs, but the shift to value based reimbursement. Plus, I think it might help to answer the question above.

The first ACO thread is in response to an NGACO report from CMS that was shared by David Muhlestein.

In response to David’s tweet, Adam Solomon offered his perspectives in this tweet storm:

Sorry to chime in late. Our NGACO experience was very interesting. Our benchmark was based on our historical utilization for a similarly attributed population. They then added a very low trend factor to come up with a final target.

In the end, our PBPM cost was actually lower than the benchmark, but we still owed over $5 million to CMS. What happened?

Because the baseline year risk was calculated in the 2014 model and year 1 was the 2016 model, they couldn’t directly compare the acuity of the two populations. Therefore, the utilized a ratio comparing our trend to that of others. Our RAF score didn’t jump as much as theirs.

So our RAF “decreased” suggesting our active population was healthier than our baseline. That accounted for over $2.5 million dollars of “loss.”

The other hit was the way they calculated stop loss. Sure, there was an elective level of aggregate stop loss, but they also assigned a PBPM cost for individual stop loss based on expectations for number of patients with claims over the 90th percentile.

Because California has historically high costs, they estimated that we would have an abnormally high number of patients that exceeded that threshold. That was something like a $20 PBPM hit or another $3.5 million of artificial cost to us.

In the end, although we saved CMS money, we still needed to pay them for our “loss.”

Separate from that, the NORC Report noted above uses a different methodology to estimate savings. Instead of using ourselves as a baseline, they used a regional reference population.

The saddest part for us was that our utilization was always at the top end with little room for improvement. As an example, here’s admits/k for year 2 NGACOs. We’re dark blue.

In a separate tweet storm, Farzad Mostashari, Former National Coordinator at ONC and now Founder of Aledade offered this look at the ACO results:

1/ 2017 #MSSP #ACO Results!
ACOs have scaled rapidly across the country!

In aggregate, the 472 ACOs were accountable for nearly 9 million Medicare beneficiaries and $95 Billion- that’s a quarter of all fee for service, and almost half of the entire Medicare Advantage market.

2/ If you add up all the actual costs versus benchmarks, these 472 ACOs were collectively $1.1B under their benchmarks (more on whether that’s the right counterfactual later).

Medicare shared $780 million in payments with the ACOs, netting the taxpayer $313M

But wait!

There’s lots of evidence that the benchmark under-estimates the savings produced. @JMichaelMcW et al have shown convincingly that a true “difference in difference” approach would show substantially higher net impact.

The green eyeshades folks at CMS OACT said add 60%

3/ So that means that the best guess for MSSP savings is actually $1.75B in 2017, with Medicare paying out $780M (45%)- not a bad deal for the taxpayer!!!

That does NOT count savings that come from lower costs to the taxpayer from Medicare Advantage rates that are keyed off FFS

4/ Here’s how the CMS actuaries put it:

And on quality- the average ACO earned 92% on their quality scores- and the scores improve the longer you are in the program according to the ACO Rule’s Regulatory Impact Assesment.

(The Aledade average quality score applied was over 95%, and as high as 99.8% #GoKANSAS)

6/ Lemme say that again….

ACOs saved Medicare over a Billion dollars in 2017.

Cheaper than FFS, cheaper than MA.

And they did it without cutting payments to doctors or narrow networks

And they did it with higher patient quality.

That’s called delivering what was promised

7/ the Track 1 ACOs more than held their own here

Best guess is that Track 2/3 generated 190M in savings (w 60% spillover) and received $95M (50%)

Track 1: $1.5B in savings, $685M in payments (44%)

(I’m still a believer in moving to 2-sided risk to help weed out ACO squatting)

8/ You know what was a great investment? Giving small and rural physician-led ACOs an advance payment to help them invest in infrastructure and setup costs.

It was critical to the success of several of our @AledadeACO

More commercial payors should do this!

9/ But what this initial release does not help us do is see which type of ACOs are creating the most value.

My guess is that it’s not much different from what the CMS actuaries found for PY 2016- ACOs that include hospitals and directly control more of the cost of care do worse

10/ The “low revenue” ACOs (in the OACT analysis – less than 10% of total cost of care came to them) were only a third of the lives in the program, but generated roughly 98% of the savings.

THAT is why in the ACO Rule CMS proposed letting them stay in low risk models longer

11/ That was the entire thesis behind “the paradox of primary care leadership” that informed the founding of @AledadeACO

That is also why @AledadeACO partners with independent physician practices, not hospitals like others do.

Health Reform and Physician-Led Accountable Care
Even though most adult primary care physicians may not realize it, they each can be seen as a chief executive officer (CEO) in charge of approximately $10 million of annual revenue. Consider that a t…

12/ A quick analysis by the amazing @Travis_Broome divides these 2017 results by whether the ACOs included a “facility/CCN” (CAH, RHC, FQHC don’t count for this purpose) –

Same pattern- 95% of the savings are coming from the ACOs that don’t include hospitals.

13/ Only 3.5M of the 9M ACO-attributed benes were cared for by the smaller ACOs that didn’t include a hospital facility- and they generated 95% of the savings.

If you’re an independent practice seeing these results and the policy direction, why would you join a hospital ACO?
So how did @AledadeACO do?

We are always very transparent with our results- even when things didn’t go our way- to look for ways to be better, and to make policies better that are holding back broader success.

This article 2 years ago was full of pain.
The Opportunities and Challenges of the MSSP ACO Program: A Report From the Field
This article provides a detailed description of a Medicare Shared Savings Program accountable care organization (ACO)’s actions and results, to increase understanding of the challenges and opportunit…

15/ This was a good year for @AledadeACO

Only 1/7 freshmen ACOs made savings- but we have learned to set expectations- it’s a long game.

But 5/8 ACOs that were sophomores or older will get checks.

And 2/3 that didn’t get MSSP crushed it in commercial contracts.

16/ But I’m more proud that EVERY ONE of our @AledadeACO have measurably improved health for the patients we are accountable for.

We have increased wellness visits, transitional care, and chronic care management- and that’s translated into lower ED visits and readmissions

17/ So where do we go from here?

The #MSSP #ACO program has been a hugely successful motivator of nationwide transformation, but it can be reformed, and I believe @SeemaCMS is on the right track.

Here’s what I would expect might change between the NPRM and the final ACO rule:

18/ The GlidePath to risk reduces ACO squatting, and brings revenue-based downside risk to MSSP, but the lowered gainshare in 1st 2 years (25%) is not enough to get new entrants and ACO investments.

(as suggested) “low revenue” ACOs should get higher gain-share and lower MSR

19/ The refined benchmarking method gives greater predictability by allowing risk adjustment and regional trending-which is great!
But the cap on risk adj (3% over 5 years?!) don’t control for rising risk and introduces gaming on falling risk

Instead of a cap, do renormalization

20/ Concern about “windfall profits” led to an ill-advised proposal to cap regional efficiency at 5% – In Medicare Advantage if you are efficient, you get to keep the difference, which has spurred huge innovation in the space. why blunt improvement? 100% tax brackets are not good

21/ Credit to CMS for trying to fix the unintended “regional comparator” problem- where rural ACO savings are reduced in direct proportion to market share. But the “national trend blend” proposal makes NO SENSE.

Let’s just take ACO benes out of the regional comparison please!

22/ But the biggest impact of these results on the proposed rule should be on the idea that the way to benefit the Trust Fund is to protect it from ACO earnings.

These caps, etc reduce ACO earnings- and ACO motivation/participation- and therefore reduced benefit to Medicare

23/ The NPRM RIA estimates through 2024 these caps push $390M in lower ACO earnings, but lower ACO participation under these policies will INCREASE claims costs by $60M- and would prevent beneficiaries from receiving the benefits of the program. That’s not the right balance

24/ The magic of accountable care is when physicians & Medicare partner together to sustainably align financial incentives, help beneficiaries and the Trust Fund.

Medicare hasn’t behaved like some commercial payers who are still seeing zero sum. Let’s hold onto that partnership

I’ll let you be the judge after reading through these threads. Are ACOs going to really improve healthcare and lower costs? Will the best healthcare win? Or will the people who understand the government rule making process and healthcare accounting be the big winners?

As I read through these, it seems like you better get your accountants and healthcare policy experts ready. That brings joy to every doctor’s ears…I’m sure!

Early Lessons from the Front Lines of Value-based Care: How One APM Has Impacted Community-Based Oncology Practices

Posted on June 11, 2018 I Written By

The following is a guest blog post by Dr. Charles Saunders, CEO, Integra Connect.

The Oncology Care Model (OCM) – an alternative payment model introduced in July 2016 by the Center for Medicare and Medicaid Innovation – launched with the ambitious goal to further delivery of higher quality, more coordinated cancer care at a lower cost. Participants include 184 practices representing approximately one-third of community oncologists in the US. They receive a so-called “MEOS” (monthly enhanced oncology services) payment of $160 per beneficiary per month for the duration of a qualifying 6-month chemotherapy period, plus the opportunity to earn a share of savings if they exceed a target threshold. In return, oncologists are expected to take on increasing accountability for patient outcomes and well-being, while also generating sustainable cost savings across all co-morbidities and care settings, into the patient home.

OCM Performance Period 1 Results Exposed an Unexpected Misalignment   

As part of the OCM program, CMS tracks practices during 6-month intervals – so-called “performance periods” – then shares results back about one year later. In February 2018, practices participating in the OCM program received visibility into Performance Period 1 (PP1) data, including savings achieved, aggregate quality score, and effectiveness of identifying eligible patients. While most practices were unsurprised by their performance scores, many did not anticipate the extent to which CMS would recoup MEOS payments that it deemed paid in error. The most common scenario involved patients with co-morbidities who, while receiving chemotherapy and related services, also visited other providers regularly. Therefore, the oncology practice did not represent the required plurality of E/M codes for that beneficiary. It was not uncommon for practices to be asked to return up to 30% of the sum they had been paid – a major financial hit.

Lack of Data Hinders Practices’ Ability to Accurately and Proactively Identify Beneficiaries

In May 2018, practices received their Performance Period 2 (PP2) Attribution Lists, which summarized which CMS beneficiaries met OCM eligibility criteria, which episodes were attributed to each respective practice, and episode start dates from January 1, 2017 through June 30, 2017. Unfortunately, because there is a significant lag between actual Performance Period and delivery of CMS findings – delayed up to nearly a year after each performance period has ended – OCM participants were unable to retroactively apply PP1 learnings to PP2.

Why is this especially problematic? Practices are faced not only with MEOS recoupments for erroneous payments but, with only a 1-year window to submit claims, are often unable to bill in full for patients who were missed. Indeed, there are many opportunities to miss appropriate patients, as practices needed to have an accurate view of: 1) all beneficiaries; 2) those with a qualifying diagnosis; 3) those with a new chemo episode; 4) those not only prescribed an oral agent, but those who subsequently filled it; 5) those not in a hospice; and more. Given all the dimensions to track and measure, practices without advanced tools face delivering enhanced services that they cannot correctly bill for.

Best Practices from Community-Based Oncology Practices Include Robust Data

What best practices arose to get attribution right? A vanguard of OCM practices realized that they would need to take proactive steps to enable near real-time visibility into their patient populations, embracing the tenets of population health management. Below is an example of the best practices adopted by several of these community-based oncology practices:

  • Increased transparency into oral chemotherapies: Existing practice protocols did not open an episode when oral agents were prescribed, since there was no in-office administration. To address this, the practice introduced a rule-based algorithm to identify all OCM eligible patients, including those who had been prescribed orals. In addition, they enlisted a combination of automated and personal follow-ups to validate qualification and ensure orals had been filled.
  • Avoidance of duplication: To identify missed billing opportunities while also reducing the risk of duplicated claims, practice leadership invested in a robust analytics tool that enabled personalized queries at the patient level. These reports compared eligibility against their practice management report to identify gaps, from unpaid and unbilled to denied.
  • Targeted patient intervention: To balance the practice’s financial and clinical objectives while optimizing OCM performance, the practice introduced complex care management services and employed a series of triage pathways. This approach ensured engagement with attributed beneficiaries and decreased avoidable high-cost events among at-risk patients, such as inappropriate ER visits and inpatient stays.
  • Optimized treatment choices. As part of its commitment to ensure each patient received the most effective treatment for his or her disease, the practice provided increased transparency around the availability of equally effective generic or biosimilar drugs. They also supported better end-of-life planning for patients facing second or third-line therapies not expected to provide any clinical benefits, but that could significantly degrade remaining quality of life.
  • Continuous performance improvement: To track the effectiveness of these quality improvement initiatives, the practice leveraged its analytics tool to monitor resource utilization and care management performance, then intervened to address outliers in real-time.

In short, to optimize performance under the OCM, practices are beginning to leverage the data to which they already have access – both clinical and financial – to risk-stratify their patient populations; identify OCM eligible patients; and gain near real-time visibility into quality and cost performance. Practices are also investing in better data integration and analytics that enable rules-based identification of eligible patients.

Population Health Analytics Help Practices Be Proactive and Succeed Under the OCM

Oncology is on the forefront of value-based care adoption and these early experiences from the OCM have provided a guide for other specialties. Based on their early results, what has come to the forefront is the need for a combination of comprehensive data management and robust analytics, coupled with the principles of population health management, which enable practices to step up and take control of the cost and quality for their attributed populations.

Moving to Health Care from Sick Care

Posted on December 29, 2017 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the biggest themes I’ve heard in 2017 was the need for health care to shift from our current sick care system to really focused on the whole person. This has largely been driven by the move to value based reimbursement, but health data has also illustrated this problem.

The good news is that technology can help with this challenge as well. Technology can sift through all the data and provide insights that can help a healthcare provider personalize the wellness care a patient really needs. That’s a powerful idea that I think we’ll see starting to bloom in 2018.

I found this powerful image that describes at least part of our health problems in the US:

There’s certainly a link between happiness and health, but beyond that I think you could replace happier with healthier. It’s fascinating to consider how much healthier we’d all be if we could just slow down and simplify our lives. As someone who does far too much, this idea resonates with me. However, it also is very apparent how hard it is to change this culture.

Where do you see the move from sick care to health care happening? Are there initiatives, organizations, companies, etc that are doing a good job in this regard? What are you doing in your personal life to slow down and improve your health? We look forward to hearing your thoughts in the comments.

The Future of Small Medical Practices

Posted on December 27, 2017 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the questions I get most often relates to the future of small practices in healthcare. I’ve heard a lot of people make really great arguments for why small medical practices have an extremely challenging future in healthcare. We’ve all heard stories of large healthcare organizations eating up small medical practices left and right.

For the longest time, I’ve argued that this is all just part of a cycle of doctors selling to hospitals and then doctors hating life as an employed doctor and so they return to running their own practice. This cycle seems to be playing out and most doctors still hate being employees. However, there are a lot of other forces at play that makes it harder for doctors to go out and start their own independent medical practice again.

As I look at the biggest healthcare trends, none of them point to a brighter future for the small, independent medical practice. In fact, most of them make it even harder for small medical practices to survive.

For example, the shift to value based reimbursement is something that should be a great thing for small medical practices that have been known to provide the highest quality, personalized care. While this is true, must of value based reimbursement is as much about understanding and applying the data to a population in order to improve the overall health. How many small practices are going to be capable to do this type of data analysis?

If you extrapolate this further, it’s hard to imagine a future healthcare system that’s not built on the back of data. If that’s the case, he who holds the data holds the power. It’s worth asking if even the hospitals and health systems will be large enough to have the data they need on their patients. Or will even the largest hospitals and health systems need to work with massive companies like Google and Amazon who are currently collecting data at rates that no hospital could even consider?

This is a scary and exciting future that is a topic for another post. However, from a small practice perspective, this could be a good thing. If large corporations like Google and Amazon have the data needed to improve healthcare, then it’s possible that those corporations will enable small practices to survive. It could level the playing field for small practices that are trying to compete with large health systems.

What’s certain is that every healthcare organization is going to have to move beyond just the EHR. Sure, the EHR will be a requirement for every medical practice, but I believe it will only be the start. For small and large medical practices to survive, they’re going to have to start exploring what other technology they can implement to provide a better patient experience. The good thing is that small practices can be nimble and implement new technology quickly and without as much bureaucracy. The hard part is that they have to do so with a smaller budget.

What do you think about the future of small medical practices? Will they survive? Should we be making efforts to make sure they survive?

Embracing Quality: What’s Next in the Shift to Value-Based Care, and How to Prepare

Posted on June 13, 2017 I Written By

The following is a guest blog post by Brad Hill, Chief Revenue Officer at RemitDATA.

Whatever the future holds for the Affordable Care Act (ACA), the shift to value-based care is likely here to stay. The number of providers and payers implementing value-based reimbursement contracts has grown steadily over the past few years. A survey of 465 payers and hospitals conducted in 2016 by ORC International and McKesson revealed that 58 percent are moving forward with incorporating value-based reimbursement protocols. The study, “Journey to Value: The State of Value-Based Reimbursements in 2016” further revealed that as healthcare continues to adopt full value-based reimbursement, bundled payments are the fastest growing with projections that they will continue to grow the fastest over the next five years, and that network strategies are changing, becoming narrower and more selective, creating challenges among many payers and hospitals as they struggle to scale these complex strategies.

Given the growth of adoption of value-based care, there are certainly many hurdles to clear in the near future as policymakers decide on how they plan to repeal and replace the ACA. A January 2017 report by the Urban Institute funded by the Robert Wood Johnson Foundation revealed that some of the top concerns with some potential scenarios being floated by policymakers include concerns over an immediate repeal of the individual mandate with delayed repeal of financial subsidies; delayed repeal of the ACA without its concurrent replacement; and a cutoff of cost-sharing subsidies in 2017.

With the assumption that value-based healthcare is here to stay, what steps can you take to continue to prepare for value-based payments? The best advice would be to continue on with a “business as usual” mindset, stay focused and ensure all business processes are ready for this shift by continuing to:

  1. Help providers establish baselines and understand their true cost of conducting business as a baseline for assuming risk.
  2. Analyze your revenue cycle. Look at the big picture for your practice to analyze service costs and reimbursements for each – determine if margins are in-line with peers.  Identify internal staff processing time and turnaround times by payer. Evaluate whether there are any glaring issues or problems that need to be addressed to reduce A/R days and improve reimbursement rates.
  3. Determine whether there are reimbursement issues for specific payers or if the problem is broader in nature. Are your peers experiencing the same issues with the same payers?
  4. Capture data analysis for practice improvement. With emerging payment models, hospitals and practices will need expertise in evaluating data and knowledge in how to make business adjustments to keep the organization profitable.
  5. Determine how you can scale and grow specific payment models. Consider, for example, a provider group that maintains 4 different payment models and 10 different payers. The provider group will need to determine whether this system is sustainable once payment models shift.
  6. Break down department silos in determining cost allocation rules. Providers need a cost accounting system that can help determine exact costs needed to provide care and to identify highest cost areas. Cost accounting systems are typically managed by the finance team. There needs to be clinical and operational input from all departments to make a difference. Collaborate across all departments to determine costs, and design rules and methodologies that take each into account.
  7. Compare your financial health to that of your peers. Comparative analytics can help by giving you insights and data to determine your practice’s operational health. Determine whether you are taking longer to submit claims than your peers, have a higher percentage of denied claims for a specific service, percentage of billed to allowed amounts and more.

Though change is a part of the healthcare industry’s DNA, ensuring business processes are in line, and leveraging data to do so will help organizations adapt to anything that comes their way.

Roadmap to Succeed in Value Based Contracts with Mark Anderson

Posted on June 7, 2017 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Nishanth Varghese, Marketing Director at Innovaccer, sat down to talk with Mark R. Anderson, Chief Operating Officer at East Texas Healthcare System and a well-known thought leader with over 44 years of healthcare experience, about the ongoing shift from fee-for-service to value-based reimbursement.

This is an extremely important topic and Mark Anderson never pulls punches and has a deep understanding of healthcare. So, take 34 minutes and let Mark catch you up to speed on what’s happening with value based contracts.

Is there anything Mark Anderson didn’t cover in this discussion that we should know. Anything that he talked about where you have a different perspective? Let’s hear your thoughts in the comments.

Reinventing Claims Management for the Value-Based Era

Posted on February 16, 2017 I Written By

Provider claims management as we once knew it is not enough to thrive in a value-based era. Here’s what you need to know about taking claims management to a higher level.

The following is a guest blog post by Carmen Deguzman Sessoms, FHFMA, AVP of Product Management at RelayAssurance Plus RelayHealth Financial.

Provider claims management as we know it can no longer exist as a silo. With the rapid transformation from fee-for-service to value-based models, denial rates remain high–nearly 1 in 5 claims–despite advances in technology and automation. The complexity of value-based payment models almost guarantees an increase in denials, simply because there’s so much to get wrong.

For provider CFOs and their organizations to be effective–and thrive–in this environment, the touchpoints across the revenue cycle continuum must be re-examined to see if there are opportunities for improvement that have not presented themselves in the fee-for-service era. One such area is claims management, which is ripe to be elevated into an integral part of a denials management strategy.

What are the implications for providers? Well, for perspective, consider the savings realized through electronic claims submission.  CAQH research reveals that submitting a claim manually costs $1.98, compared to just $0.44 per electronic transaction. Likewise, a manual claims status inquiry costs $7.20 versus $0.94 for processing electronically.

This paper outlines the features and benefits of a technology platform that is geared toward elevating traditional claims management into the realm of strategic denial prevention and management, along with some recommended denial management best practices.

From Claim Scrubbing to Strategic Denial Management

Simple claims management as we know it is becoming obsolete. By “simple” we mean a claims process with a basic set of capabilities: creating claims, making limited edits, and ensuring that procedures are medically necessary. Today, a new class of integrated claim and denials management solutions augment this traditional approach to include pre- and post-filing activities that help automate and streamline claim submission, proactively monitor status, and expedite the appeals process for those that are denied.

In its simplest form, denials management can be defined as a process that leads to cleaner submitted claims and fewer denials from payers. But there are a lot of interim steps and variables that lead to “clean” claims, and a growing number of factors that influence denials. With the shift to alternative payment models and increasing consumerism, it’s more important than ever for providers to process claims properly the first time and to keep staff intervention to a minimum.

A big part of denials management is to improve the quality of patient data at registration, the source of many errors that lead to denials. Nonetheless, integrated claim and denial management processes span the entire revenue cycle, and technology brings new opportunities to manage costs and improve efficiencies. For example, having the ability to manage claims within a unified platform that can share and integrate data with the organization’s EHR prevents the need to toggle back and forth between systems to determine the status of a patient encounter.

A comprehensive claims management platform that advances denials management efforts integrates the following capabilities:

  • Eligibility verification prior to claim submission. It sounds pretty basic, but eligibility and registration errors on claims continue to be the top reason for denials. Automating the real-time verification of eligibility data helps identify avoidable denials and alert staff to claims needing attention before submission.
  • Maintenance of and compliance with oftenchanging payer business rules and regulatory requirements, including Medicare and state-specific updates, so that claims go out as cleanly as possible on the front end. With multiple payers and a growing roster of alternative payment models, manual in-house maintenance of edits is becoming an overwhelming task.
  • Digitization of attachments for Medicare pre- and post-payment audits, commercial claims adjudication and integrity audits, and workers compensation billing support. Integrating digital data exchange into the claims management workflow can help providers better control administrative costs, ensure regulatory compliance, and help automate and streamline claims processing and reimbursement.
  • Visibility into claim status lifecycle, with guidance for proactive follow-up. This lets providers only focus on those potential “problem” claims, and address any issues, before they are denied or delayed.
  • Automation of repetitive and labor-intensive tasks such as checking payer portals or placing phone calls to determine the status of pended or denied claims. This helps drastically reduce the amount of staff time spent perusing payer sites, and sitting on the phone on hold when an answer can’t be found.
  • Predictive intelligence to determine timing of payer acknowledgements and requests for additional information, as well as when payment will be provided. Analytics-driven claims management provides insight into how long responses should take, alerting providers when follow-up is required.
  • Management of remittances from all sources. Automated management of transaction formats, adjudication information, remittance translation and posting can help reduce A/R days, boost staff productivity, and accelerate cash flow.
  • Denial management and data analysis to guide corrective action and prevent future denials. Revenue cycle analytics can monitor the number of claims per physician, payer, or facility, enabling the health system to be proactive in interventions.
  • Creation and tracking of appeals for denied claims, including pre-population and assembly of appropriate forms. This not only helps cut down on resource-intensive manual work and paper attachments, but streamlines the appeals process.

Tying these capabilities together within an exception-based workflow helps address the challenge by providing visibility into problem claims. At-a-glance access to claim status helps cut down on the back-and-forth between billing departments and payers, and allows staff to focus only on those claims that require attention.

Pulling it all Together

Once you’ve integrated these capabilities, what are some of the claims management best practices to improve denial management and prevention? Consider the following actions:

  • Embed denial management within the entire workflow–Strong edits lead to clean claims, whether they pertain to Medicare, commercial payers or state-specific regulations. Edits should be constantly refined and seamlessly implemented, and pushed out to providers as often as possible–at minimum on a twice-weekly basis.
  • Adopt analytics-driven claims management–Claims management systems and connectivity channels to payers (i.e. clearinghouse) produce a wealth of operational information, most importantly data evidencing the speed of the payment path and claim status. Analyzed and served up in meaningful formats, this data becomes targeted business intelligence that can help providers better see obstacles and identify the root cause of denials and payment slowdowns.
  • Resolve issues before they result in denials–Providers should know claims location and status at all times. For example, has the claim been released by the EHR system? Has it been received and approved by the payer—or does a problem need to be addressed? Has a problem been rectified? Has the claim been released to a clearinghouse? Historical trends establish guidelines for the timing of events (e.g., whether claim status or payment should have been received from a particular payer by a certain date).
  • Be ready to identify claims denials and submit appeals. Nationwide revenue cycle statistics show that 1 in 5 claims are denied / delayed and can be avoided with the right software and better business processes.  In addition 67% of these denied claims are recoverable Identifying denials and submitting appeals to supply information not included on the initial claim can recoup lost revenue. To help streamline the process, additional claims information, such as medical records or lab results, should be supported by structured electronic attachments rather than faxed paper records or uploaded files to payer portals.

An Ounce of Prevention = Big Returns

Reducing and managing denials will have a significant impact on any healthcare organization’s bottom line. First, it costs $25 to rework a claim, and success rates vary widely. Additionally, when denials must be written off, the drop in patient revenue may total several million dollars for a medium-sized hospital, according to Advisory Board estimates.

The new look and feel of claims management is moving quickly toward analytics-driven, exception-based processing. By implementing and leveraging these capabilities and best practices in a cloud environment, providers can look forward to accelerated cash flow, reduced denials, increased automation with less staff involvement, and lower IT overhead.

About Carmen Sessoms
With over 20 years of progressive strategic leadership and healthcare experience in product management, business development, strategic planning and consulting, Carmen Sessoms has worked with all organizational levels in the ambulatory and acute care markets for patient access and reimbursement.

Prior to joining RelayHealth, Carmen was the regional vice president of operations for an outsourcing firm, where she led the eligibility side of the business and was instrumental in many process improvements that brought efficiencies to the company, its provider customers and their patients. Additionally, she has 10 years’ previous experience with McKesson in Product Management roles in which she directed projects related to the design and development of revenue cycle solutions, including initiatives with internal and external partners.

Carmen is a past president of the Georgia HFMA chapter, a recipient of HFMA’s Medal of Honor, and holds the designations of CHFP (Certified Healthcare Financial Professional) and FHFMA (Fellow in HFMA).

How To Choose Tools For Physician-Patient Engagement

Posted on September 22, 2016 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

To transition from fee-for-service reimbursement to value-based care, it’s pretty much a given that we have to do a better job of getting patients engaged with their physicians and overall plan of care. However, despite the array of intriguing digital health and mobile technologies we have available to get the job done, it’s still not clear exactly how to do it.

But according to one health IT exec, it all boils down to understanding how the various tools and technologies work and integrating them into your practice. Dr. Ali Hussam, CEO of outcomes data collection firm OBERD, suggests that the following tools are particularly important. I’ve listed his suggestions, and added some thoughts of my own:

  • Educational technologies: Physicians can use these tools to make sure patients are prepared to have an intelligent discussion of their health status, he notes. My take: It’s hard to argue that this makes sense; in fact, this concept is so important that I’m surprised it isn’t mentioned more often as part of the broader patient engagement picture.  
  • Electronic questionnaires: Hussam argues that since value-based care calls for quantifiable outcome measurements, it’s smart to use electronic questionnaires, which are more appealing, efficient and sophisticated than paper tools. My response to this is that while it’s a good idea, it will be important that the questionnaires be based on well-defined measures which the provider organization trusts, and these may not be easy to come by at first.
  • Wearables: Patients may already be using wearables to monitor their own health metrics, but it’s time to make better use of their presence, Hussam suggest. Physicians can step up their value by using the information to improve the quality of health discussions and intervene in response to the data if needed.  It’s hard to argue that he’s right about the potential uses of wearables. However, there’s a lot of doubt about their accuracy, so my sense is that many physicians are still reluctant to make use of them given the clinical accuracy questions which still bedeviled these devices.

Along with recommending these approaches to engagement, Hussam offers some tips for implementing patient engagement technology, including:

  • Focus on patient outcome: Hussam recommends sending a patient-determined outcome as the focus of care, and explaining to patients how engagement technology can help them meet this goal. Plain and simple, this sounds like an excellent idea, as patients are more likely to succeed at meeting goals they have embraced.
  • Solicit feedback: Effective engagement tools “should offer patients a sense of individual attention and intimacy by soliciting feedback about individual patients’ entire healthcare experience,” along with offering care data. He argues, I think compellingly, that this exchange of information could help providers succeed under merit-based incentive payment programs.
  • Encourage responses to questionnaires: As Hussam noted previously, providers must collect data to succeed at outcome-based payment models. But he also notes correctly that these questionnaires and help patients achieve their desired health outcomes by tracking what’s going on with their health. No matter how you couch things, however, patients may need additional encouragement to fill out forms. Perhaps it would make sense to have med techs go through the questionnaires with patients prior to their physician encounter, at least at first.

As Hussam’s analysis suggests, engaging patients isn’t just a matter of presenting them with shiny new technologies. It’s critical to align patient use of the technologies with goals they hope to meet, and to explain how the tools can get them there.

Otherwise, both patients and providers will see little benefit from throwing engagement tools into the mix.

When Will Doctors Teach Patients to Not Come In for a Visit?

Posted on July 8, 2016 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been thinking and writing a lot about the shifting medical reimbursement world. Technology is going to be an enabler for much of this shift and so understanding the changes are going to be key to understanding what technology will be needed to facilitate these changes.

As part of this thinking, I recently wondered when a doctor will start teaching patients when they shouldn’t come for a visit. I realize this is a bit of a tricky space since our current liability laws scare doctors from providing this kind of information. Dealing with these liability laws will be key to this shift, but if we want to lower the cost of healthcare and improve the patient experience, we need to make this change.

Turns out, we already do this in healthcare, but it’s not so formal. Plus, it’s usually the older, more experienced doctors that do it (from my experience). I think the older doctors do this for a couple unique reasons. First, hey’ve had years of experience and so the patterns of when someone should go to a doctor or not are very clear to them since they’ve seen it over and over for 30 years. Second, they aren’t as worried about patients returning in the future, so they’re not afraid to educate the patient on when they shouldn’t come for a visit. Third, these older doctors are likely tired of seeing patients for something that’s totally unnecessary.

We’ve had an older pediatrician that did this for us and our children and we loved the experience. In some ways, I think he just liked to hear himself talk and we loved it as parents. There’s no handbook you get as a parent and so we wanted to learn as much as possible about how to take care of our child. Since we had 4 children, we were able to use that knowledge pretty regularly, but even so, it was hard to remember 6 months or a year later what the doctor had told us. It was all very clear when he explained it in the exam room, but remember when to take them to the doctor and when to wait it out was often forgotten 6 months later.

The decision of when to go to the doctor and when not to go to the doctor is always a challenge and I always forget when I should and when I shouldn’t. Far too often my wife and I error on the side of caution and take our kids in for needless visits. We don’t want to be irresponsible parents and not take them. With my own personal health, I likely wait too long to go to the doctor because I’m busy or I can just tough it out when a quick visit to the doctor would make my life better and avoid something worse.

I guess this is why we see so many health decision tree apps out there. They try and take the collective knowledge and help you as a potential patient know if you should go in for the doctor visit or not. However, most of them are really afraid to make a hard conclusion that you shouldn’t go to the doctor. Instead, they all end with some sort of disclaimer about not providing medical advice and that you should consult a healthcare professional for medical advice. I’m not sure how we overcome the liability of really offering a recommendation that doesn’t need the disclaimer. Although, this is exactly what many of us need.

What do you see as the pathway forward? Will the consumer health apps be our guide as patients? Will doctors start spending time educating us on when to come for an office visit and when not to come? Will they want to do this thanks to ACOs and other value based reimbursement? Will doctors leverage the consumer health apps or a PHR tool to help their patients with retention of the concepts they teach them about when to come in for a visit?

The Virtual ACO

Posted on April 26, 2016 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

“Virtual ACOs may be the next big thing for small practices,” says our host Dr. Tom. “I want to talk about how independent practices can lead and not just follow the shift to value-based care.”

Who here has looked at or talked to someone about virtual ACOs?

My guess is that most small practices haven’t really heard about it. Maybe it has to do with most doctors being too busy to consider other innovation. I’ll admit that the idea of a virtual ACO is a new one to me and so I was interested in the discussion that Dr. Tom from Kareo led on virtual ACOs.

The concept of a virtual ACO makes sense. Basically use technology to provide coordinated care across the care system. In fact, that’s what most patients think is already happening with their care, but we know it’s generally not happening. We all know it should and most doctors would embrace the ability to have the right information in the right place so that their patients get the right care. I don’t know anyone who’s against that principle.

However, as was pointed out in the chat linked above, the financial model for a virtual ACO is up in the air. There’s no clear financial model that makes sense. The care model makes sense, but the financial model is a mess.

Dr. Tom did make this assertion in the virtual ACO discussion:

Although S. Turner Dean responded with something we’ve talked about quite a few times before:

I love Dr. Tom’s optimism that this new world of value based reimbursement simplifying things, but I’m not sure it will be any simpler than fee for service. That’s not even taking into account the fact that we have the whole infrastructure set up to handle fee for service and that we know how it works. Set that aside and I’m still not sure that a virtual ACO would be any less complicated than our current fee for service world.

What do you think of the concept of a virtual ACO? Will it simplify medicine? Will it help doctors love their work again? Will it help the independent physician practice survive?

Full Disclosure: Kareo is an advertiser on this blog.