With the rise of value-based-reimbursement, healthcare delivery organization (HDO) consolidation remains a popular lever for increasing the scale and capabilities needed for value-based care models and transition to risk-based arrangements. With these challenging shifts, it is critical that HDOs remain vigilant in securing a strong revenue cycle management fortified by accurate timely data. The means to accomplish this is through a strong commitment to clinical documentation improvement (CDI), a program for enhancing medical data collection to maximize claims reimbursement revenue while improving quality of care. Successful implementation of CDI contributes to efficient cash flow and optimizes claims processing from payers considering factors beyond traditional length of stay.
Without CDI, providers may decrease their chances of receiving value-based reimbursement because insurers are increasingly approaching reimbursement from the template offered by the Medicare Severity-Diagnosis Related Group payment model. This model adheres to risk-based methods such as the Hierarchical Condition Categories (HCCs). The Centers for Medicare & Medicaid Services (CMS) implemented HCCs in 2003 to adjust Medicare Advantage (MA) health plan payments at the patient level. HCCs assign a risk score based on certain chronic diseases and patient demographic data to predict care delivery costs for these beneficiaries. When payers take this approach, HDOs unable to provide complete and accurate documentation will surely receive low payments.
Exercising actuarial muscle through pursuit of value-based reimbursement opportunities from private payers
attracts patients with affordable, high-quality care under alternative payment models. And private payers prefer to partner with organizations engaging in value-based care.
The infographic below provides data-driven insights regarding the following key points:
- CDI program historical execution in the inpatient setting.
- Commonalities and differences between inpatient and outpatient CDI.
- MACRA Quality Payment Program and importance of CDI program in maintaining reimbursement and financial standing.
- Growth of Medicare Advantage contracts and corresponding increased focus of outpatient CDI on HCCs.