the team approach to value based reimbursement

The TEAM Approach to Value Based

ReimbursementPresented by:

Tracy Bird, FACMPE, CPC, CPMA, CEMC, CPC-I

Medical Practice Advisors.com

tbird@medicalpracticeadvisors.com

913-856-0181

1

Learning Objectives

• Discuss the foundational pillars necessary for success under value based reimbursement

• Analyze current fee-for-service duties and processes for modifications that enhance value-based concepts

• Distinguish TEAM strategies for successful processes for delivery of care

2

3

The Triple Aim

Quality Patient Experience Cost

4

5

Strategic Incompetence

6

The Pillars for Transforming Business Processes

• Culture

• Breakdown Silos

• Communication

• Lean Processes

• Technology

7

Fundamental Change for Success

• Culture is the way you do business

• Underlying rules and beliefs

• It is how everyone in the organization

interacts with one another and patients

8

CommunicationFundamental Change for

Success

• Intentional two-way communication is a must

• Patient engagement is the goal

• Clear communication is central

to coordination of care

• Incorporate technology for

improved communication

9

Fundamental Change for Success

10

Fundamental Change for Success

Technology

11

The TEAM Defined

12

Transitioning from FFS to VBR

Fee For Service Value Based Care

13

14

Front Office/Admin – Fee For Service World

• Patient calls for appointment- gives name and type of insurance (New) patient

• Patient calls for appointment- gives name (established patient)

• Patient arrives for appointment. Demographics are reviewed. If updates are necessary, will have patient write them down for billing to enter later.

• Copies insurance card – for billing to enter later

• May or may not ask for money - if so, typically it is co-pay only. If patient states they don’t have it, no co-pay is collected.

• Nursing is notified the patient has arrived.

15

Role of Patient Engagement Specialist

16

Patient Experience Specialist- Value Based World

17

Additional Roles and Responsibilities of PES

18

19

Coding/Billing Department Fee for Service World

20

21

Business Service Team- Value Based World

• Relies on front end activities to ensure clean claims

• Electronic claim scrubbers• Rules engines to replace manual processes

• Monitors lag time of charge entry• Accountability

• Claim submission edits – 277 report review

• Electronic remittance posting

• Pay close attention to adjustments – coded correctly

22

Business Service Team Value Based World

• Denial management • Develop experts with tiered levels of sophistication

• Measure denial percentages

• Aged trial balance

• Patient statements• Reduced or replaced by credit card on file

• Patient collections

• KPI’s and benchmarking

23

Business Service Team- Value Based World

Additional considerations for Revenue Cycle• Use technology to boost staff productivity

• Manage the AS/R using lean principles. Eliminate non-value added work

• Constantly audit the work of the technology

• Evaluate how to capture non-billable cost associated with VB care

• Know your cost to provide services

• How will bonus money be applied to the universe of claims for a period the bonus covers?

24

Business Service Team- Value Based World

25

Medical Assistants/Clinical Staff- Fee for Service World

26

Medical Assistants/ Clinic Staff – Value Based World

• Scrub charts 2-3 days in advance

• Active participant or run the team huddle

• Call patient from waiting room, introduce with a smile

• Take vitals and other pertinent information

• Prepare patient and room for the exam

• Inform the patient the provider will be in shortly

• Assist the provider during the exam, when appropriate

• Ancillary and diagnostic services (i.e. draw lab, EKG, immunizations, injections, etc.)

• Explain and summarize the visit and verify the patient understands

• Patient liaison

• Perform a patient satisfaction survey before discharging patient from the room

• Warm handoff to check-out

27

Nursing Staff- Fee for Service World

28

Nursing Staff- Value Based World

• Scrub charts 2-3 days in advance

• Active participant or running the team huddle

• Triage (in person or via phone)

• Review pharmacy refill calls

• Help Medical Assistants when behind

• Conduct group classes for better patient outcomes

• Maintain patient care flow throughout the office

• Assist with AWV, IPPE’s, etc.

• Ancillary and diagnostic services (i.e. draw lab, EKG, immunizations, injections, etc.)

• Prior authorizations (especially if specialty group) – important to work with coding and billing

• Care Managers (assist with CCM, TCM, etc.)

29

Care Manager/Nursing- Value Based World

30

Care Manager/ Nursing – Value Based World

31

Nursing Staff- Value Based World

32

Things to Think About in the Value Based World

33

Providers- Fee for Service World

34

Providers – Value Based World

35

Providers Coding & Documentation- Value Based World

36

Things to Think About- Value Based World

37

Coding Staff- Fee for Service World

38

•Role of the coder•Data entry•Reviewing every note• Emailing providers to append their notes• Staying at their desks

Coding Staff- Value Based World

39

•Role of the Coder• Educator•Reviewer• Investigator•Observer• Team player

Team-Based Care

40

Patient Centered Care

41

How do you Get There?

42

How to Create a Value Based Delivery Model

43

• Identify patients with chronic conditions•Who frequent the emergency department•Who has uncontrolled chronic conditions•Who has higher incidence of no shows•Who is non-compliant with their medications•Who is calling for refills without a visit

How to Create a Value Based Delivery Model

44

45

Final Thoughts

46

47