As the healthcare industry is transitioning from volume-driven to value-based model of reimbursement, a significant new challenge has been created for healthcare executives: Managing the Gap. And just what is the gap? It’s that period of time when your organization is being paid on a fee-for-service basis, while at the same time is diligently working to improve quality and lower costs in preparation for value-based reimbursement. Everyone must learn to work under both the old and new reimbursement models simultaneously in order to successfully manage the gap. There is no light switch that will trigger the end of fee-for-service as we know it and immediately transition to value-based reimbursement models. In fact, it is highly likely that we will see both reimbursement models in place for the foreseeable future.

We are challenged to manage the use of health care dollars effectively while also measuring quality outcomes. It is vitally important for health care executives to address the financial viability of their organizations while simultaneously managing patient care in a much broader way than in the past.  Transitioning from Volume-Driven to Value-Based Model without loss of revenue and reimbursement can be a daunting challenge.

Managing the Gap

It is imperative that revenue capture for your fee-for-service component be accurate and compliant, while also addressing ways to eliminate waste and managing the entire continuum of care.  This will require accurate diagnosis coding to address risk adjustment factors, case mix index and other indicators that will be used in ACO and other value-based reimbursement models as well. Successful healthcare organizations will be the ones that are adept at managing the gap to ensure success regardless of the reimbursement model (volume-based or valued-based).

  • Staffing – Chances are your staff already is stretched thin. BDA can assist with the complicated process of creating the appropriate mix of inside staff with outsourced resources for maximum efficiencies.
  • Budgets – It’s imperative that your initial budget accurately reflects the acuity of care your organization is providing. BDA can assist you in determining your budget to avoid undervaluing the services you provide.
  • Accuracy – Coding and documentation practices must be refined to appropriately capture the services provided by ACOs. BDA will work with you to ensure that diagnosis coding and associated CPT code capture is accurate and complete.

The real lesson here is that regardless of the compensation model, your coding and documentation practices must accurately reflect the care being provided.