In the current healthcare panorama, providers are expected to shift from volume-centric caregiving to the value based reimbursement model. This approach is beneficial to every entity involved – patient, caregiver, and payer. As the new model of value based healthcare sweeps across the care-giving domain, care providers and insurers seem to be struggling to keep up. Advanced medical billing solutions have to be strategically incorporated toward population health management, patient engagement, and health care payment. With the paradigm shift from fee-for-service to the pay for performance model, adapting to the new normal requires significant adjustments. Whether it’s restructuring or a completely new design, the medical billing process needs to adapt toward value-based payment through advanced medical billing solutions. Payers and healthcare organizations need to follow medical billing solutions that are geared to comply with value based payment healthcare.

What is Value-based Reimbursement in Healthcare?

value-based Reimbursement in Healthcare

Value-based Reimbursement payment is an approach wherein the care provider’s reimbursement is directly linked to the quality of care that is provided by the healthcare organization/ provider. It is measured through patient health outcomes, which provides benefits to healthcare providers for their quality and efficiency in the process of caregiving. It is a healthcare culture that is based on evidence-based practice. Now, you may be wondering what evidence-based practice is and how it works. Evidence-based practice is a system of value-based payment agreements, within which providers are compensated for proven health improvements, reduction of the effects and occurrences of chronic diseases, and an overall elevation of health. What evidence-based practice essentially entails is an overall responsibility of the health of the patients involved.

The present transition from the fee-for-service to pay-for-performance model carries plenty of potential for healthcare organizations, but it also comes with its set of challenges. For this transition to be smooth, there are some factors that need to be taken into consideration. The starting point for this would be to maximize your knowledge of value-based payment models and the strategic options towards advanced medical billing procedures. Value-based reimbursement in health care may seem like a simple process, but its complexity comes into play during execution. The methodology involves financial incentives that motivate caregivers to steer away from volume-based care and towards approaches that focus on increasing the quality of care and decreasing the costs involved. Within the health care reimbursement dynamic, advanced medical billing processes have to be aligned, medical billers and coders have to adapt, medical billing management adjustments have to be made, and healthcare payments have to be modified. There are multiple dimensions to value-based reimbursement in health care and providers can adopt the methods that suit their practice most closely. The Multiple Approaches Towards value-based Care are,

CMS value-based Care

CMS value-based Care

To increase clarity towards this government-led transition of value based reimbursement, let us go back to the first steps. At the beginning of 2019, healthcare providers had to choose between Merit-based Incentive Payment Systems (MIPS) and an Alternative Payment Model (APM). The closest transition from the fee-for-service model would be towards MIPS, but it involves CMS value-based care. This value based reimbursement model adjusts healthcare billing on the basis of scores towards meaningful practices, the efficiency of care, improvements in practices, and quality of care. This format of specialty billing involves comparisons with peers in the same specialty towards resource maximizations. Medical billing and coding is expected to adjust accordingly. On the other hand, APM guarantees a 5% increase in payment every year for the first 6 years of the program. However, there is a risk involved in this approach too. Caregivers that don’t match up to the relevant metrics fail to reap the benefits of shared savings in healthcare reimbursement.

Shared Savings:

This method involves an innovative approach towards value based healthcare that rewards caregivers for reduced spending on patient treatments by giving them a part of the savings. Healthcare organizations can adjust their medical billing and coding procedures to create value based reimbursements of this nature through case management and advanced medical billing solutions.  

Shared Risks:

In this value-based healthcare model, risks are shared by giving saving targets to caregivers. If these targets are not successfully met, caregivers are obliged to share cost savings with payers and might also be penalized through payments. This healthcare reimbursement method ensures that caregivers keep their costs in control. Medical billing and coding systems can be adapted to this model through custom medical coding solutions.

Pay for Performance Healthcare Model

Performance Based Healthcare Model

In a pay for performance healthcare model, value-based payments in healthcare involve financial incentives. Health care billing solutions and automated healthcare solutions are designed to make healthcare payments based on rewards for satisfying quality metrics. This method involves benefits for the patient, but also for providers that increase care-giving quality, efficiency and engagement through advanced medical billing.

Accountable Care Organizations (ACOs)

This popular value-based payment healthcare model is one in which caregivers and healthcare organizations are compensated to improve health outcomes and meet quality metrics. This approach involves healthcare payments that are similar to the ones above. value based payments in healthcare take account of enrolled patients and evaluate multiple dimensions of care, with relevance to peers in the same area. Medical billers and coders utilize ICD 10 coding solutions to adapt to this system.

Episode of Care:

Also called the bundled payment model, this healthcare reimbursement strategy involves an understanding of accountability with payers for fixed episodes of care. Savings are augmented through the elimination of unnecessary care episodes, which increases overall quality. This encourages a focused approach on key metrics and healthcare billing solutions can be adjusted accordingly. Custom healthcare solutions can be incorporated within the caregivers organization to accommodate this model through advanced medical billing.

Value Based Healthcare Benifits

Strategies to Boost Value-Based Care  

Strategies to Boost Value-Based Care

The transition from a fee-based to a value-based model seems time-consuming for providers and healthcare practices. Payers adopting new payment structures under the value-based reimbursement model must follow some best practices to ensure a smooth transition. Here are some key strategies to successfully transition toward a value-based reimbursement model.

1. Evaluate the Patient Population  

In value-based reimbursement, payers can evaluate the patient population for risk stratification and population health management analysis. Leveraging this strategy will enable payers to inform providers about the members needing greater engagement in managing their health. Besides, population health registries can benefit providers if used for tracking patients’ progress.   

Moreover, population health management also enables payers and providers to avoid spending that isn’t important. And this happens by just tracking patients closely and ensuring that preventive care interventions are given even before the condition worsens. This saves up the cost of urgent or emergency care visits.

2. Manage Financial Risks 

Value-based billing is quite risky, especially for the financial stability of both providers and payers. When partnering with payers through value-based reimbursement models in healthcare, healthcare providers are exposed to more financial risks than the payers.   

In a value-based health payment system, it’s observed that payers gradually transfer the financial risks onto the provider. On the other hand, providers are busy advancing their care management strategies to ensure better quality care delivery. 

3. Improvement in Care Delivery 

The primary aim of value-based reimbursement systems in healthcare is to improve the quality of care delivered. Value-based reimbursement also puts a lot of emphasis on cost containment strategies to ensure quality care is affordable for patients. And to achieve these goals, healthcare leaders suggest investing more in Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes. These healthcare facilities decrease healthcare spending by controlling wasteful activities and boosting the quality of care.

4. Measure the Quality of Care and Goals

Providers leverage advanced billing services and quality improvement strategies to boost value-based care. And they are quite focused on doing this. However, payers often need help finding the transition to value-based care. But payers can effectively transition by aligning the quality measures with the goals of their provider network.    

While some payers force providers to adhere to different quality metrics between public and Commerical health plans, they should customize their quality measures. Payers aligning their quality metrics with CMS and MACRA regulations can better serve the members and ensure improved care.

5. Enhance Member Engagement 

This is quite a significant strategy for providers and payers to improve member engagement. Payers can provide all necessary information about clinicians and facilities to members that are best suited for them. Besides, payers can also leverage digital tools to provide members with data-driven information, enabling them to make informed decisions regarding their healthcare. In fact, with this information, payers can successfully adopt value-based reimbursement plans. 

Advanced Medical Billing Rules That Ensure Value-Based Reimbursement

Advanced Medical Billing Rules That Ensure Value-Based Reimbursement

Ensuring a smooth reimbursement process requires advanced medical billing solutions in a value-based care setting. It’s quite a complicated process to ensure. With the AR cycle and claim denials, staying at the top of your game seems like a rigorous battle. Nevertheless, advanced medical billing software can simplify it. But practices must adhere to some strict rules to ensure value-based reimbursements. Here are the top 3 rules- 

1. Go by Rules

Choosing advanced medical billing software can be tricky. However, opting for the one with built-in rules that can auto-update can offer some real benefits. After all, it’s always better to work smarter by using the rules to your advantage. Besides, rules in the advanced medical billing platform include auto-checking of claims accuracy on the go. This allows you to detect errors long before they are sent.   

Such rules will help you to minimize claim denials, cut down ‘take back’ requests from payers, and even avoid time taking audits. Moreover, seamless integration of these billing rules into the practice management system can effectively maintain streamlined billing workflows 

2. Avoid Overriding Claims

It’s quite a common instance that providers fail to utilize all features of medical billing solutions to get optimized results. Take, for instance, overriding justified claims edits, which could be better billing practice. Typically, this happens when the provider feels that they don’t need to change the bill if they get paid for certain services they rendered. And that could be more optimal. The receipt of initial payments doesn’t guarantee that the billing is correct. There might be some errors, and there are chances that the payers might come back for a refund.   

It’s always advisable to send a request to understand why edits are required. If the advanced medical billing software is up-to-date and adheres to reimbursement guidelines strictly, providers can get full documentation on why edits are necessary for the revenue cycle.

3. Conduct an Audit for Incorrect Payments

One of the major reasons to opt for an advanced billing system is to prevent losses in payment audits. Payers often need to gain up-to-date software or have complete knowledge of medical and payer policy regulations. They would review and pass the claims; providers get their payments. But the complication begins when payers conduct incorrect payment audits.   

To prevent this, providers must opt for advanced medical billing solutions only. The integrated rules of such advanced software are auto-updated and are extremely helpful in cutting down payment ‘take-backs.’ Preventing audit losses can ultimately stabilize the revenue cycle as well.

7 Success Tips for Medical Billing Processes for Value-based Payments in Healthcare

  1. Medical billers and coders can adopt innovative technologies to adapt to these new health care payment models. Medical billing management can take into account the current medical billing system and make the necessary changes toward reimbursement in healthcare. EHR and billing system integration software can be upgraded, medical billers and coders can encourage investments in population health, and the medical billing system can incorporate new accounting procedures. Finally, hospital management systems can create medical billing systems that can adhere to one or more reimbursement healthcare model.
  2. EHR and billing system integration should also be executed on the basis of HIPAA compliant solutions in health care billing. While choosing the reimbursement healthcare model, healthcare organizations must look at their specific goals and finalize on a model that aligns with those goals as closely as possible.  Healthcare billing and coding challenges must be analyzed and addressed by building custom healthcare solutions.
  3. Healthcare billing and coding procedures, along with the chosen value based care CMS, must be directed at keeping costs as low as possible. The model selected should further be aligned with the medical claims management solutions and have a proven record of success through pioneer models. value based payments in healthcare can be drastically increased through collaborative strategies.
  4. Healthcare billing and reimbursement in health care can be increased through strategic data sharing and integration methodologies. Information sharing to standardize administrative and billing processes can keep costs low through preventive healthcare. Adopting sound healthcare revenue cycle solutions can significantly enhance the overall workflow during the transition process.
  5. Evaluation of patient population is another prerequisite toward choosing the ideal reimbursement healthcare model. value-based care CMS should be analyzed through patient risk stratification. Ultimately population health management is a means for preventive care, which can be further compounded through innovative remittance software solutions.
  6. Adopting sound medical credentialing solutions, while switching to a value based care payment model can ease the financial risk on the organization. As the provider takes on more financial risk, these innovative solutions ease the burden through automated care management strategies.
  7. An integration of personal caregiver goals with those of the payers and provider networks can prove beneficial. An added aligning with value-based care CMS can further accentuate quality.


Value based healthcare is no longer the future of healthcare. It is the present. Organizations have to maintain momentum and adapt to the need of the hour. With integrated EHR and practice management software, and advanced medical billing solutions, the transition to value based care models can prove highly beneficial to all healthcare entities. With high-quality outcomes, superior patient engagements and a higher volume of patients, the advantages of value based care and advanced medical billing are numerous. Successful implementation will directly translate into lower costs of care and reduced medical errors. The healthcare industry is changing, and organizations and caregivers have to maintain the pace with advanced medical billing solutions. These advanced medical billing solutions offer superior accounting capabilities with increased revenue generation and reduced procedures


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