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Value-Based Reimbursement Knowledge Hub

Health care payment reform aims to fix the broken reimbursement system in the U.S. See what it takes to thrive in this new, value-based payment environment.

Medical Group & Practice Success

Patient engagement
Successful patient engagement starts with being able to identify gaps in care — the visibility into knowing where you’re not providing the quality care you should be. Once these gaps are identified, your system should target the patient populations in need and help get them in the door, effectively driving better health outcomes across patient populations and improving your quality score. It takes a tremendous level of insight and work to accomplish this level of patient engagement and population health; make sure you have a vendor who can help. 

Meeting quality measures at the point of care

If your practice is billing Medicare, fulfilling quality measures isn’t an option; it’s a requirement. Both PQRS and Meaningful Use have moved past the incentive-only phase and are now penalizing practices that don’t comply with program requirements. The penalties are substantial, and can upset cash flow for medical groups and small practices —  the total potential penalty for Medicare fee-for-service reimbursement is expected to double between 2015 and 2018.1

Manage practice performance 
With the future of health care now coming into focus, one thing is clear: Succeeding with PQRS and other value-based programs is virtually impossible without an intelligent EHR workflow. The EHR is a revenue driver in this new world with reimbursement tied to clinical outcomes more than ever – and increasing in the years to come.

But the right EHR must be supported by the right partner. One that helps medical practices tackle the complexities of value-based programs and stay focused on patients.

You want an EHR that removes the complexities of VBR. Check that yours provides actionable insight at the point of care, surfaces clinical measures where they’re easiest to satisfy and least obtrusive, and is continually updated to keep your practice current with program compliance. 

Manage risk
The changing reimbursement environment requires more than software. To take on risk and avoid penalties, you need to accurately document and bill for each diagnosis. It’s helpful to have insight into which diagnoses result in higher or lower risk scores at the point of care (the point of diagnosis). Check that you have a vendor or partner who gives you this insight, and make sure your quality scores are as strong as they can be. 

Reporting and compliance 
Reporting requirements vary based on program. In an ideal state, your practice works with a vendor who takes on reporting for you. But not all vendors will report on their clients’ behalf, leaving providers to fend for themselves trying to figure out very complicated and time-consuming reporting methods. With PQRS, for example, providers first determine whether to report as an individual or a group. Then, they choose from  four following reporting methods:
  • Claims-based: This labor-intensive reporting method requires individual eligible providers (EPs) to submit Quality Data Codes (QDCs) for each of their PQRS measures. This method has a low success rate, and CMS has indicated it will not support claims-based reporting indefinitely.
  • Qualified PQRS registry: Reporting to a participating PQRS registry tasks EPs with determining whether to report individual measures or measures groups. This method can significantly tie up provider and staff time, unless handled by your vendor. 
  • Qualified Electronic Health Record (EHR): Individual EPs and groups lean on functionalities within their certified EHR technology (CEHRT), or on a qualified EHR Data Submission, to report PQRS quality measures via this method. It’s important to determine your vendor supports this functionality and can fulfill on your behalf. 
  • Qualified Clinical Data Registry (QCDR): EPs must apply and qualify for this reporting method. To report, individual EPs submit to a registry, certification board, collaborative or other CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking. 

1. FierceEMR, “CMS: Providers face millions in Meaningful Use penalties,” February 12, 2015.

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