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by Venkat Sharma on April 28th, 2017

​Part 2 of 2: Positioning your finances for success
 
The Boy Scouts are right.
 
Their motto — “Be prepared” — is equally apt in healthcare, as providers seek to be ready for whatever new practice demands lie ahead in the complex world of healthcare reimbursement under a quickly evolving value-based care model.
 
In my first blog of this two-part series, I discussed how essential it is to start with a probing look at the foundation of your existing billing operations. Only when the holes or cracks in that foundation can be addressed and revenue leakage stopped can providers focus on implementing new processes, tools and partners to be prepared to navigate and thrive in the future of healthcare.
 
As noted, you must look at everything. Examine every aspect of your current billing process — from your payer mix to what can be moved to the front office to improve patient collections in an era of high-deductible health plans and greater out-of-pocket responsibilities. Ensure you fully understand each and every payer plan and your contractual obligations, that your provider credentialing is in meticulous shape, staff is appropriately trained (and retrained…and retrained) and that you’ve evaluated and tightened the encounter (charge capture) process. That all combines for a strong foundation upon which to build.
 
This evaluation is time-consuming and highly complex, and is typically when you make the decision to get outside, expert help — help that can be singularly focused on this evaluation and recommendations for improvement, based on industry best practices, and assume complete or shared responsibility for your day-to-day billing operations in an outsourcing or co-sourcing arrangement. Through this partnership, providers and staff can be freed to deliver exemplary service to your patients.
 
The type of revenue cycle performance partner that providers need today is much more than the old “mom and pop” small billing operations. It’s not enough to simply move your standard billing function from your own back office to one down the street or across the country. You need a comprehensive partner with “skin in the game,” going at-risk with you based on agreed-upon metrics, and offering deep industry knowledge and a robust set of integrated technology, data, processes and people. These include:
 
  • Revenue cycle management
  • Credentialing services
  • Coding and coding audits
  • Practice management and consulting
  • Electronic health record (EHR) reporting and optimization
  • Eligibility checking and prior authorization
  • Population health analytics 

Quality, Care Coordination and Population Health

This combination of revenue cycle performance solutions is essential to success in the coming months and years. It’s not “just” dealing with requirements of MACRA’s Quality Payment Program and whatever changes are made to the Affordable Care Act; providers face new responsibilities, risks and opportunities within a growing number of other care coordination and population health initiatives. These will require new alliances with other providers within emerging accountable care organizations (ACOs) and other alternative payment models (APMs) that will demand peak efficiency, accountability and data sharing on levels typically unheard of for smaller practices, clinics and even health systems.
 
It’s a challenging yet exciting time to be in healthcare. With the right revenue cycle performance partner, you can be freed to have healthcare be fun, personally and professionally rewarding and profitable again. That’s why iHealth exists — to deliver technology and services to minimize administrative burden, increase provider revenue and reduce costs so both providers and patients can thrive. It’s a responsibility and a privilege we take very, very seriously.
 
This is the second of two posts by Venkat Sharma, iHealth CEO, on how to transform your revenue cycle performance to navigate and thrive in an evolving world of value-based healthcare.
 

by Venkat Sharma on April 20th, 2017

​Part 1 of 2: Positioning your financials for success
  
What’s wrong? Where does it hurt? These are the basic questions providers ask their patients to begin the process of diagnosing a problem and determining a course of treatment that optimizes the outcome. They’re also the kinds of questions we at iHealth use to open a dialog with a potential revenue cycle performance customer.
 
You see, the infrastructure of healthcare practices, clinics and health systems is much the same as patients. It’s the foundation for good health — in this case, good financial and operational health. Especially in an era of rapid change and a dizzying mixture of regulation and competition, providers must carefully consider those questions to determine where inefficiencies are occurring that can plague their profitability and sustainability. Only through that thoughtful diagnostic process can providers implement changes that maximize time, staff and other resources so they can operate at peak efficiency and achieve desired results today and in the future.
 
As clinical, financial and satisfaction outcomes — the Triple Aim of healthcare goals — become increasingly intertwined within payment methodologies, providers are coming to learn that the old ways of operating a successful healthcare business must evolve to keep pace. The challenge is, physicians went to medical school to care for patients, not business school to manage a company; they and their staff don’t typically have the time and deep knowledge needed to focus on new requirements that will keep their doors open and their business successful.
 
This is particularly true now that the Quality Payment Program (QPP) transition year began Jan. 1 under MACRA, the Medicare Access & CHIP Reauthorization Act of 2015. Whether providers choose the MACRA payment track called MIPS, the Merit-based Incentive Payment System, or Advanced Alternative Payment Models (APMs), it’s going to change how physicians and other eligible clinicians will be evaluated and paid for keeping patients healthier.
 
As a provider, the impact won’t hit your bottom line until 2019, so why take action now? It’s important in 2017 because the data and outcomes tracked and achieved this year will determine whether you’re paid more, through incentive payments, or less, due to penalties, just two short years from now. (See board advisor Justin Barnes’ insightful MACRA blogs below.) This new payment model begins with Medicare so will initially affect providers to varying degrees however, as usual, private payers are expected to follow suit with similar programs.

So while 2019 may seem a long way away, it’s not. Regardless of how Medicare and private-payer regulations continue to evolve, it’s clear what practices do today can quickly grow, erode or even eliminate an often narrow bottom line.
 
In survey after survey, providers admit they’re not ready. In a recent study by Healthcare Informatics magazine and SERMO, 70 percent of the more than 2,000 U.S. physicians across various specialties surveyed reported that they either need help or aren’t prepared at all to face changing business models under MACRA. They often don’t have a solid strategy and confirm that they lack the resources to make it happen. HI Editor-in-Chief Mark Hagland concluded that in this critical juncture for healthcare providers, “many physicians — especially in smaller practices — remain woefully unprepared.”
 
Fixing the Foundation
So what steps can be taken take now to prepare for this evolution? First, as in building a house, a practice’s financial foundation must be rock solid. And let’s face it…every healthcare organization has its quirks and standard operating procedures that can either strengthen or erode their bottom line and crack the foundation of their practice’s financial stability in the face of constant change.
 
Worse, you place your financial success in the hands of only a handful of persons, sometimes only one. This in-house staff may have done a great job for decades, but they are subject to illness, vacations, and retirement. Plus it’s frankly just hard to keep up with the latest nuances of each payer when the billing team is working at full speed just to serve your existing patient load and get through the workday.
 
So even with a stable and experienced billing, coding and credentialing person or team, it’s a lot to be prepared to handle in-house, or with a small “mom-and-pop” billing company. Whatever your team’s size and capabilities, it can always benefit from expert help that’s laser focused on the latest industry changes as these game-changers are considered and implemented.
 
Most providers admit they don’t believe their current systems, people and processes are sufficient to the task. In September 2016, Black Book released a report of end-to-end revenue cycle management solutions showing that a full 85 percent of provider organizations surveyed are in revenue cycle management (RCM) replacement mode, and 70 percent are considering outsourcing or co-sourcing their revenue cycle operations. 94 percent of chief financial officers believe transformed revenue cycle processes will enable them to become more efficient and positively impact their organization’s financial health, though half worry their budgets won’t allow them to afford the comprehensive solutions they need. Others cite concerns about protecting valued, long-time staff in the process.

But many who’ve taken the plunge say it’s working…and working well.
 
Analyzing the Black Book report, Becker’s Healthcare noted that 82 percent of practices and ambulatory clinics outsourcing or co-sourcing their revenue cycle services since fall 2015 have reported decreased number of rejected claims and reduced time in receiving payments from payers. The challenge of recruiting and retaining  skilled business staff reported by 97 percent of independent group and solo practices — so damaging to an already fragile claim-management process — almost immediately “fell off of the radar” of concerns for most providers after outsourcing their billing. Fortunately, many practices retain their valued staff members by retraining and focusing their roles toward more revenue-generating activities.
 
Black Book also reports that more tech-savvy and cost-conscious physicians now graduating from medical school are looking at outsourcing as an effective and efficient alternative to in-house staff. This helps them achieve their dream to launch their own practice versus becoming an employee of a larger organization. To accomplish that, they’re comfortable with setting up a streamlined operational structure that includes external billing-support services; this enables them to focus on optimizing the health of their patients while minimizing financial risk. They maintain their independence and feel comfortable they’re being appropriately compensated for their services.
 
Evaluate All Aspects of Current Billing Processes
Just like making improvements in your own home, getting a provider organization’s financial house in order depends on having a solid foundation upon which to build. Finding the holes and cracks in your current foundation requires a methodical analysis of each of your current processes and how they work together. That’s the only way to see where the many handoffs and other potential causes of inefficiency are occurring and causing revenue leaks. Only then can you make educated decisions on how to implement best practices — some of which may be new to you — that plug those leaks and meet your ever-evolving needs.
 
This is only step 1 of a multi-step process (more on that in my next blog), but it’s critical to reinforce that this single step entails evaluating all aspects of your current billing process, including:
  • Understanding and establishing achievable expectations based on payer mix
  • Knowing the nuances of each of your contracted payers
  • Automating processes wherever possible
  • Creating a customer-friendly experience that includes making patient payments simple and upfront, improving cash flow and increasing patient collections while fostering satisfaction, retention and growth
  • Evaluating workflow for impact of value-based care reimbursement models 

And then of course there are the related and critical aspects of provider credentialing, the encounter (charge) capture process, the intake process, and your approach to working your accounts receivable.
 
As noted, that’s a lot for your team to bite off. Plus, few organizations have staff with the ability to step back and take a focused and unbiased look at “the way things always have been done.” Is it any wonder that, as previously noted, 70 percent of Black Book’s surveyed providers are considering outsourcing their revenue cycle management to an outside expert?
 
iHealth is one of those experts. Our mission is to help our customers succeed and strengthen the overall healthcare ecosystem by eliminating administrative inefficiency, using our strength in innovation, technology, and global infrastructure. We’re proud of our 20-plus-year history of doing just that, and are dedicated to going 100-percent “at risk” with our customers, delivering a custom-tailored set of billing and related services and tools that, together, create a sustainable competitive advantage for both our customers and our company.
 
With such an effective partnership, you can get your house in order now and set your practice to effectively navigate the future of healthcare so you can thrive for many years to come.
 
This is the first of two posts by Venkat Sharma, iHealth CEO, on how to evaluate opportunities for improvement within your existing billing, coding and credentialing operations and implement best practices to succeed under MACRA and other emerging value-based payment initiatives. The next blog in the series will address the mixture of technology, services and industry knowledge required of an effective revenue cycle performance partner.
 

by Justin Barnes on February 7th, 2017

​The path to value-based care and reporting under the new Quality Payment Program is undeniably paved in patient data. As clinicians dive into first-year monitoring and reporting under MACRA, the strength of their technical infrastructure will directly impact one’s ability to successfully meet reporting requirements and outcome improvement and resource utilization targets.

As providers lay the IT groundwork to support MIPS, APMs and other quality-based payment programs, a keen eye on the integration, customization and optimization of technical resources based on your practice’s unique needs and factors will be paramount. Most practices have already made substantial investments in healthcare technology acquisition, but lack time and internal resources to derive maximum benefit from those investments. The vital next step is properly putting those tech resources to use by securing dedicated HIT expertise to support your organization’s new quality reporting and clinical process improvement goals.

Integrate
Providers’ ability to integrate financial and clinical data sets will set the stage for operational and patient data analysis. Bringing as much data into view as possible will establish a robust view of patient data from which to glean insights on things like care gaps, utilization trends, patient risk assessment and clinical performance metrics.

Use IT staff, or outside expertise if internal resources are limited, to take stock of IT infrastructure and data assets. Keep the rising number of patient data capture points and care coordination partners in mind as you establish your data management process to streamline integration work down the road.

Customize
Once data access needs have been met and a firm understanding of MIPS or APM reporting measures relevant to a practice of your size and specialty is established, begin the process of customizing your EHR technology to help meet specific quality reporting requirements. In some cases, EHR template and workflow customization and dashboard creation can help practices quickly and routinely target measures and KPIs pertinent to the practice.

Bear in mind that MIPS Advancing Care Information (ACI) reporting requirements vary depending on the edition of your certified electronic health record technology (CEHRT). Intimate knowledge of Quality Payment Program specifics for the healthcare organization will be required to customize tracking metrics and deliver on quality reporting objectives. Don’t underestimate the value of internal expertise.

In some instances, providers may not be able to optimize functionality in the EHR and/or health IT systems already in place. While most leading EHRs are equipped to meet MIPS and APM requirements, 25% to 50% of practices are likely to find limitations in their platforms that could necessitate an EHR replacement strategy.

Optimize
Test the process for submitting reporting metrics ahead of time to garner your health organization an opportunity to address any issues uncovered. A proactive approach to testing the quality reporting system could also offer your practice a chance to see if you can meet more than minimum reporting thresholds to potentially earn bonus points and incentives, particularly during first-year “pick your pace” reporting flexibilities.

Streamline technical workflows and leverage IT wherever possible to create efficiencies for patient engagement and throughput. Using tech resources to make it easy for patients to do business with your healthcare organization will be a vital element in meeting evolving consumer demands and maintaining business viability.

Make sure you implement a technical infrastructure that supports your facility’s financial and clinical goals. Many hospitals and practices have wonderful technology resources in place that can help their organization thrive under the Quality Payment Program and other programs on the horizon. Taking the time to establish a solid data integration foundation, customize tech resources, and continually optimize workflow and the patient engagement process will be invaluable to clinicians in the new value-based landscape.

This is the third of four blog posts by Justin Barnes being simultaneously published on www.RCManswers.net. Earlier blogs in this series touched on financial and clinical best-practices in the march towards MACRA. The next blog in the series will address the role of staff and/or partner expertise in realizing quality payment program success. 

by Justin Barnes on February 1st, 2017

​In the inaugural reporting year of MACRA’s new Quality Payment Program, quality measures and clinical practice improvement activities will collectively account for 85 percent of MIPS composite scores used to determine Medicare reimbursement penalties and incentives for healthcare providers. As clinicians prepare to embark upon MIPS reporting, knowledgeability on clinical performance metrics and standing heading into and throughout QPP participation will be essential to meeting reporting and care delivery objectives under the new value-based payment model.

Providers have a unique opportunity under relaxed first-year reporting requirements to layer new clinical analytics practices in with financial, technical and administrative best-practices incrementally. The clinical insight providers are poised to glean from data gathered through the new quality payment model will increasingly drive both reimbursement and evidenced-based care protocol moving forward.

Clinical Quality: Know Where You Stand
When building a game plan for clinical reporting under MIPS, cognizance of the clinical areas where a practice has traditionally experienced success can inform quality metric selection heading into participation. By opting for quality measures that sync with identified high-performing areas, providers can put their best foot forward in the push to avoid penalties, achieve positive payment adjustments and potentially earn bonus incentives.

It is also important that participating entities be well-versed in the broad array of reporting measure options available under MIPS. Appoint QPP subject-matter experts, either internally or through a trusted external partner, to help the healthcare organization identify best-fit reporting metrics, including any that may align to specific practice specialties. (Twenty-two of the more than 270 quality measures, for example, relate specifically to radiology.) Take advantage of measures that appear across multiple categories to reduce reporting burdens.

Garnering the clinical data and analytics needed to execute on MIPS reporting and track outcome trending over time may require new resources and/or roles within the organization.

Clinical Improvement: Action via Analytics
Effective population health management and care coordination are at the crux of value-based care targets the QPP aims to meet (better outcomes, higher patient satisfaction, and lower costs). Many of the MIPS improvement activity measures center on collecting and sharing patient information with care teams, referred providers, and the patient themselves. The objective is to optimize patient outcomes by partnering with facilities across the continuum of care.

Practices should focus on expanding communication with beneficiaries and patient care teams, as well as specialists, to meet clinical improvement activity goals. Identify new, cost-effective opportunities for patient engagement, communication, education, and empowerment in the clinical process to satisfy both MIPS measure requirements and evolving healthcare consumer demands.

The clinical data capture and analytics practices ushered in by MACRA will bring never before seen transparency to healthcare that providers can use to begin understanding and addressing utilization, cost and care patterns. The clinical process monitoring and analytics infrastructure that providers establish today will increasingly serve value-based care programs and population health management objectives in the years to come.

The first blog in this series touched on ways to cement revenue cycle best practices heading into MACRA. The next blog in this series will touch on best practices for technical success.

This is the second of four blog posts by Justin Barnes being simultaneously published on
www.RCManswers.net
 

by Justin Barnes on January 11th, 2017

With kickoff of the inaugural MACRA reporting period nearly upon us, many healthcare providers will greet 2017 with quality payment program objectives top-of-mind. The new pay-for-performance reimbursement landscape will usher in the adoption of new clinical and technical workflows as physicians work to meet the goal of driving better patient outcomes through smarter healthcare resource utilization. The cornerstone of these initiatives, however, is an effective financial strategy.
 
As providers gear up for reporting under MIPS and other quality payment models, assessing financial infrastructure before layering in payment program initiatives ensures future plans are built on a solid foundation. By cementing effective revenue cycle management practices up front, practices can be confident their organization is securing all financial resources available, which may serve the organization elsewhere in the push to value-based care.
 
Optimize Your Revenue Cycle Today
Stabilizing and optimizing existing revenue streams to ensure the practice isn’t leaving “money on the table” is a fundamental and often overlooked element of any practice strategy. Regardless of the path you elect to pursue under MACRA’s quality payment program, renewed emphasis on the following key areas can garner more revenue for your organization starting today.
 
  • Coding: Ensure accurate coding, documentation support and audit practices to optimize revenue and to prevent rejections, denials and audits. These best practices can add 2%-10%+ revenue alone.                    
  • Denials: “White glove” claims prep work on the front-end coupled with strong appeals practices on the back-end end can help plug revenue leaks and add 1%-3% increased cash flow. 
  • Contracts: Providers should analyze contracts and scrutinize payer reimbursements every 6-12 months to ensure revenue due to the practice is collected. 

Tap into New Revenue Opportunities Under MACRA
Once core revenue cycle management (or I call it revenue cycle performance) practices are solidified, it’s important to understand key performance indicators, trending and the cost of operations before heading into QPP participation. Look for any new earnings opportunities that may benefit the practice moving forward.
 
Incentive Options: Reach out to commercial payers to evaluate any value- and risk-based contracts your practice may qualify for. Take advantage of plan- and state-based incentive programs that may not be advertised.
  • Practice Support: Does your practice qualify for funds set aside to help small and rural practices? The MACRA final rule provisions $20 million each year for five years to fund training and education for small practices of 15 or fewer clinicians and practices in rural areas. 
  • Focus on the Right Measures: Identify quality metrics that your practice has a proven success record with to alleviate reporting burdens and maximize revenue opportunities under MACRA.  
  • At-Risk Partners: Many providers will turn to outside expertise to facilitate participation and reporting under MACRA and the quality payment program. Look for partners who will go at-risk with you to make sure maximum ROI is seen. 

Set Your Practice Apart Moving Forward
As you work to hit all the right points from a reporting perspective under the QPP, make sure you don’t neglect the business-101 objective of making it easy for patients to do business with you.
 
The average practice can easily qualify for incentives under new performance-based payment systems. First-year flexibilities mean physicians can stave off initial losses and earn incentive and bonus payments under relaxed requirements. There won’t be a better opportunity to implement a strategy for future success under MACRA. Care providers who proactively engage with new payment and care delivery models, and cultivate the right partnerships and expertise, will unequivocally have more opportunity in the future.


This is the first of four blog posts by Justin Barnes being simultaneously published on www.RCManswers.net. The next blog in this series will touch on best practices for clinical success in the march toward MACRA.