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The TEAM Approach to Value Based
ReimbursementPresented by:
Tracy Bird, FACMPE, CPC, CPMA, CEMC, CPC-I
Medical Practice Advisors.com
913-856-0181
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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
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The Triple Aim
Quality Patient Experience Cost
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Strategic Incompetence
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The Pillars for Transforming Business Processes
• Culture
• Breakdown Silos
• Communication
• Lean Processes
• Technology
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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
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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
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Fundamental Change for Success
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Fundamental Change for Success
Technology
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The TEAM Defined
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Transitioning from FFS to VBR
Fee For Service Value Based Care
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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.
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Role of Patient Engagement Specialist
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Patient Experience Specialist- Value Based World
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Additional Roles and Responsibilities of PES
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Coding/Billing Department Fee for Service World
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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
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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
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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?
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Business Service Team- Value Based World
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Medical Assistants/Clinical Staff- Fee for Service World
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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
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Nursing Staff- Fee for Service World
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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.)
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Care Manager/Nursing- Value Based World
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Care Manager/ Nursing – Value Based World
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Nursing Staff- Value Based World
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Things to Think About in the Value Based World
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Providers- Fee for Service World
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Providers – Value Based World
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Providers Coding & Documentation- Value Based World
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Things to Think About- Value Based World
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Coding Staff- Fee for Service World
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•Role of the coder•Data entry•Reviewing every note• Emailing providers to append their notes• Staying at their desks
Coding Staff- Value Based World
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•Role of the Coder• Educator•Reviewer• Investigator•Observer• Team player
Team-Based Care
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Patient Centered Care
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How do you Get There?
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How to Create a Value Based Delivery Model
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• 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
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Final Thoughts
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