Managing the Revenue Cycle in a Reimbursement System that promises to reward “Outcomes” not just “Encounters”.

The Accountable Care Organization which has been a pilot program for several years is the closest Medicare has come to rewarding something other than Encounters. For the most part, The ACO’s are not realizing the bonuses they were going to receive by providing quality care and doing it cheaper. Why is this so? Most physician practices are not equipped to monitor, measure, review and record improved quality and reduced cost. It costs too much and very difficult to do.

CMS is determined to base future reimbursement on outcomes for certain diseases, but the truth is the current coding system (ICD-10) and all of its previous iterations were never designed to measure quality outcomes, or even to provide appropriate reimbursement. Not all patients are the same. The older the patients are, the more the intensity of care required.

So, the current coding system is meant to track disease and diagnosis. The new iteration provides for incredible specificity and the procedures done under the system must be carefully coded by Coders who are Critical Thinkers, experienced, and have advanced training. What is to be done?

First and foremost, anyone who touches information that affects reimbursement must be well trained and be part of a team that focuses on the “Entire Patient.” Whether in the Doctor’s office or the hospital outpatient department, Revenue Cycle Management teams must be put into place that have accountability for every facet of information that becomes a claim. Such teams should be Clinically focused and not in competition that often exists in the hospital setting. This work is done in a linear fashion rather than an interaction with team members, including the physician/clinician.

At the beginning of WW II FDR made it very clear to Mr. Churchill that the various part of the military for both countries would belong to one team with a leader for particular theater of combat. So too as we think about transitions, we need to rethink our ideas about Revenue Cycle staff, function and accountability including the most important person, the provider of care.

In creating accountability, eventually we can account for all the factors needed to determine appropriate reimbursement, even in the new theatre of Quality and Outcomes.

For over 30 years, Health Systems Management has helped and assisted large practices, hospitals and outpatient services in realigning accountability with skill level and focus on the individual patient. Please do not hesitate to contact us.

Source: http://www.modernhealthcare.com/article/20160606/NEWS/160609943