RCM Resiliency: Be Ready for Volume-to-Value Operational Pressures

May 18, 2021 By: Quadax

Protect your organization from value-based negative payment adjustments.

Before the COVID pandemic was in full swing, 84% of clinicians participating in the 2019 QPP program earned a positive payment adjustment plus an additional adjustment for exceptional performance. Although flexibilities are in place for 2021 to help ease the burden of reporting during the pandemic, they will not continue forever.

CMS plans to begin changes in the future that are more aligned with specialties and patient care, which may eliminate some providers’ ability to select reportable measures. Removing the flexibility of choice may make it challenging for some providers to control the costs of participating in programs or adversely affect their scores, leading to cuts in reimbursement.

Resiliency in your revenue cycle operations is the best defense against the high administrative costs and risks to reimbursement caused by volume-to-value payment models. The question for many organizations is how to build and maintain a revenue cycle that is robust enough to withstand disruptions while remaining efficient and cost-effective. We recommend that organizations take a holistic approach to managing the claims cycle that includes both technology and labor management.

Some best practices for building efficient volume-to-value billing operations

Maximize efficiency with existing technology

Many healthcare management systems frequently update to expand functionality. Some companies have so many updates that they go unnoticed, or staff does not have the time to learn new features. Take the time to update your system knowledge and share time-saving hints with your team. Also, confirm that claim scrubbers are updated frequently to avoid preventable denials.

Analyze performance and fill operational gaps

Take a hard look at how well your revenue cycle is performing. Over time, it is common for organizations simply to accept that there are stubborn challenges that crop up month after month. For example, rather than accepting that the front desk does not always check demographic details, provide training, set expectations for performance, and incentivize if necessary. Or, if there is an issue with a function such as insurance verification, find the root cause. If automation or technology can solve the problem, there is a high likelihood that the investment in a smoother claims process will pay for itself.

Create a team dedicated to denial management

Denials are a leading cause of labor overruns and delays in payment – costing both time and money. Protect your claims cycle with a team responsible for implementing strategies to cut denials. Ensure all facets of the claims cycle are represented (IT, coding, front desk, billing, etc.) and create detailed action plans that can track progress toward goals.

Foster awareness around measures and quality performance

Clinicians are aware of performance measures and metrics, but many do not understand the details. Share updated measure information with staff at the beginning of every year, post reminders about documentation and metrics, and provide updates on performance as the year progresses. Also, educate both clinicians and administrative staff about the financial risks and rewards that are at stake. Often staff does not realize that poor performance can directly affect their position or compensation.

Proactively manage measures

Managing QPP metrics and results can be complicated. Sorting through new mandates, deciding which measures to use, and making sure your measures are reported can be overwhelming and is not an ‘add-on’ job. One person should oversee the process from beginning to end and be given the authority to make operational decisions that can solve challenges as they arise.

A hurdle for some organizations is that they are trying to implement best practices while revenue management operations are constantly ‘putting out fires’ and stretched to the limit – working with a partner such as Quadax can be a cost-effective solution. Using a partner allows in-office staff to concentrate on patients and achieve positive health outcomes, which can be reflected in higher quality measure scores that avoid the penalties that affect cash flow.

Can you afford to lose 9% of CMS reimbursement?

The penalties for the 2021 reporting year (paid in 2023) could up to 9% for providers earning negative adjustments. As time moves on, it is expected that more organizations will earn negative adjustments to pay out the positive adjustment bonuses. All the groundwork you put in to establish best practices in your billing cycle now will help protect your organization when the volume-to-value 'shift' feels more like an earthquake in the future.

Learn more about Best Practices to Create Revenue Cycle Resiliency in our white paper. Interested in learning how Quadax can help you create an efficient claims cycle and raise QPP measure scores? Request a strategy call!

Let’s Take On The Revenue Cycle Together! 


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