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Rcm value based care presentation chicago
- 1. Success in the Value Cycle Carmel M. Roberts CEO / Administrator Valley Ob-Gyn. Clinic June 23, 2017 Valley Ob-Gyn Clinic
- 2. Agenda Revenue Cycle becomes Value Cycle Starting point The Superbill is the Foundation the Care Team builds upon Putting it all together People, Process, Technology Valley Ob-Gyn Clinic
- 3. Change in Healthcare Why this, why now? Changing rules and regulations Changing environment Changing capabilities Changing supplies Changing workforce Changing reimbursement Changing margins Changing patient expectations Valley Ob-Gyn Clinic
- 4. Valley Ob-Gyn Clinic Change in Healthcare
- 5. Current Revenue Cycle model: Process to receive payment for services rendered… Data Channels are added to modify - and provide feedback from the Revenue Cycle Model… …To the Value Cycle The Value Cycle Revenue Cycle becomes Value Cycle: What the change looks like Valley Ob-Gyn Clinic
- 6. Revenue Cycle Fee-for-service Connect charges to units of service provided Value Cycle Value-based payment model Connect costs and outcomes to units of service and charges “All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue” “The process and culture by which healthcare providers pursue quality patient outcomes and optimal financial performance through the management of clinical, operational and financial assets.” Operational Data Financial Data Clinical Data Patient Access Service Charge Capture Coding Claim Denial Mgmt. Revenue Cycle becomes Value Cycle Valley Ob-Gyn Clinic
- 7. Financial Risks Unknown cost variances – procedures, service-lines, etc. Unreliable or inconsistent Charge Capture Data Alternative reimbursement models = less predictable cash flow Pricing – difficult to develop reliable pricing models with frequent changes to guidelines and delays in new pricing model implementation Operational Risks Uncertainty of Bundling mandates from CMS – Medicare’s delay of the 3 bundled models creates change management challenges Clinical and Financial teams operating in data silos Self Insured companies are contracting directly with providers for outcomes-based care delivery with transparent pricing Clinical Risks Operational and Financial data gaps = can’t measure clinical outcomes, quality and cost data accurately Population Health Risks to your Value Valley Ob-Gyn Clinic
- 8. Manage your Value Cycle for Success Proactively managing your value cycle will result in quality patient outcomes and optimal financial performance. Value Cycle describes the full life cycle of optimizing every opportunity to achieve the best outcome for the best cost. Leverage technology and utilize a Care Team approach to achieve outcomes. Traditional RCM components Pricing Charge capture Claims performance Compliance Additional information Quality of care Patient Satisfaction Clinical outcomes Operational efficiency Risk management Valley Ob-Gyn Clinic
- 9. The Value Cycle The Value Cycle Great! (now what?) Valley Ob-Gyn Clinic
- 10. In Value Cycle Management the Superbill is the Foundation the Care Teams build on Valley Ob-Gyn Clinic
- 11. Avoid garbage in / garbage out pitfalls: The superbill becomes the anchor to value The Superbill “translates” what is performed by clinicians for patient care into charge language that can be understood by payers and patients Every service delivery workflow impacts the superbill Failure to accurately capture and align services and charges on the superbill will significantly impair the quality of your data and your decision making. Key to tying charges to clinical outcomes Valley Ob-Gyn Clinic
- 12. Why is the Superbill the Foundation? The Superbill is built with an understanding of Regulatory and Compliance Rules Contract Management Supply and Overhead Costs Location of Service The Superbill is used to capture Clinical data including What supplies were used Who performed services Location of Service A description of the nature and complexity of service performed In combination this provides basis for Value Cycle Analytics Valley Ob-Gyn Clinic
- 13. The Value Cycle starts with the Superbill The Value Cycle Billing Claims Doesn’t work without a clean, accurate, complete Superbill Overhead & Supplies Analysis/Reviews/Controls more difficult without single source of truth Denial Management Compliant Superbill helps stop unnecessary denials Procedures If you do it, you need to charge for it, which you can’t do if it’s not on the Superbill Procedures & Remittance If you do it, you need to charge for it, which you can’t do if it’s not on the Superbill Valley Ob-Gyn Clinic
- 14. The Value Cycle starts with the Superbill The Value Cycle Contract Management Can’t be done without accurate complete data, which is gathered through Superbill analysis Transparency Window into Pricing Strategy for Patients and others Pricing Strategy Implemented through the Superbill Service Line Analytics/Decision Enablement/Cost Analysis Understanding cost, making decisions and analyzing service lines can’t be done without data Service Line Analytics/Decision Enablement/Cost Analysis Understanding cost, making decisions and analyzing service lines can’t be done without data Service Line Analytics/Decision Enablement/Cost Analysis Understanding cost, making decisions and analyzing service lines can’t be done without data Valley Ob-Gyn Clinic
- 15. The Value Cycle starts with the Superbill The Value Cycle Right Patient Competition for “patients” is increasingly important. Know which population segments and conditions you are best able to impact. Right Cost Information from real data is needed in order to negotiate the best costs for Supply contracts Right Payment Contract Management, Billing, Remits, Pricing Strategy, all contribute to getting the right payment for every encounter Valley Ob-Gyn Clinic
- 16. Putting it all together to manage the Value Cycle…. Valley Ob-Gyn Clinic
- 17. Value Cycle Best Practices Valley Ob-Gyn Clinic People Technology Process
- 18. MACRA, bundled payment models, risk sharing and the Value Cycle Know your starting points Figure out what types of preventative care you are already doing or could easily implement Do a simple gap analysis of what you are already doing and what MACRA requires – fill in the gaps Adopt a Care Team approach to ensure patient engagement and to optimize care coordination and change management Valley Ob-Gyn Clinic
- 19. Value Cycle- People Develop multi-departmental team to align every workflow with the care quality goals Continuously communicate care quality goals Clearly define how each workflow impacts the value cycle Train, train, train- promote quality and upward mobility Make sure the focus is always on the end result Reward innovation- place a premium on efficiency Valley Ob-Gyn Clinic
- 20. Value Cycle- Process Understand roles and integration in the Value Cycle Review each care-team Superbill regularly Review each workflow regularly Use data to make decisions at all levels Don’t ask what data, staff and software should we install. Ask what decisions and problems do we need help with…… Increase your predictive and descriptive analytic tools- Be consistent with what you collect, how you collect it and how you take action on it, and be willing to re-assess frequently. Valley Ob-Gyn Clinic
- 21. Value Cycle- Technology Technology is available across the Value Cycle Use analytics to determine your cost to deliver specific services and your profit margins Use analytics to identify areas where you are underperforming Particularly useful to help with certain functions Scheduling Patient Communication Care Coordination Orders Tracking, Tasking, Flag High Risk patients Audit Trail for Compliance Data analytics Valley Ob-Gyn Clinic
- 22. Summary The Revenue Cycle has expanded to the Value Cycle The Foundation of the Value Cycle is the Superbill and accurate charge capture based on well document clinical decision making. Regardless of the payment methodology, the Superbill is the linchpin for complete and compliant capture of charges to assess cost of care and rate of condition incidence. This is essential for sound financial decisions, necessary to sustain and grow the healthcare mission and improve outcomes. Value Cycle Best Practices include People, Process and Technology Valley Ob-Gyn Clinic
- 23. Questions/Comments/Ideas Contact Information Carmel M. Roberts CEO / Administrator Valley Ob-Gyn Clinic, Inc. croberts@valley-obgyn.com 989-753-8453 Valley Ob-Gyn Clinic