In the current healthcare panorama, healthcare providers are expected to shift from volume-centric caregiving to value-based care models. This approach benefits every entity involved – patient, caregiver, and payer. As the new value-based healthcare model sweeps across the caregiving domain, care providers and insurers seem to struggle to keep up. Advanced remote patient monitoring systems must be strategically incorporated toward population health management, patient engagement, and healthcare payment. Adapting to the new normal requires significant adjustments with the paradigm shift from fee-for-service to the pay-for-performance model. Whether it’s restructuring or a completely new design, the need of the hour is to adapt toward value-based payment models through advanced RPM programs. Payers and healthcare organizations need to follow healthcare management geared to comply with value-based payment in healthcare.
What is Value-based Payment in Healthcare?
Value-based care programs take an approach wherein the care provider’s reimbursement is directly linked to the quality of care provided by the healthcare organization/ provider. It is measured through patient health outcomes, which benefits healthcare providers for their quality and efficiency in caregiving. It is a healthcare culture that is based on evidence-based practice. You may be wondering what evidence-based practice is and how it works. Evidence-based practice is a system of value-based payment assessment in which providers are compensated for proven health improvements, reduced effects and occurrences of chronic diseases, and an overall elevation of health. Evidence-based practice entails the overall responsibility for the health of the patients involved.
What is Value-based Care with RPM?
The transition from the fee-for-service to pay-for-performance model carries plenty of potential for healthcare organizations, but it also comes with its challenges. For this transition to be smooth, some factors need to be considered. The starting point for this would be to maximize your knowledge of CMS value-based care and the strategic options for RPM telehealth solutions. It may seem like a simple process, but its complexity comes into play during execution.
The methodology involves telehealth programs that motivate caregivers to steer away from volume-based care and towards approaches that focus on increasing the quality of care and decreasing costs. Within the healthcare dynamic, advanced value-based care and RPM have to be aligned, medical billers and coders have to adapt to Medicare value-based care technologies, medical billing management adjustments have to be made, and healthcare payments have to be modified. There are multiple dimensions to value-based primary care, and providers can adopt the methods that suit their practice most closely.
The Multiple Approaches Towards RPM Value-based Care
CMS Value-based Care
Let us go back to the first steps to increase clarity towards this government-led transition of value-based reimbursement. 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 based on scores towards meaningful practices, the efficiency of care, improvements in practices, and quality of care. This format of the healthcare payment system involves comparisons with peers in the same specialty toward resource maximization. Medical billing and coding are expected to adjust accordingly.
On the other hand, APM guarantees a 5% increase in payment every year for the first six 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.
Pay for Performance Healthcare Model
In a pay-for-performance healthcare model, value-based payments in healthcare involve financial incentives. Remote patient monitoring and telehealth are applied through healthcare analytics, 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 caregiving quality, efficiency, and engagement through advanced electronic data interchange with RPM.
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 virtual preventive care strategies that rely on healthcare cloud computing and RPM.
In this value-based healthcare model, risks are shared by giving saving targets to caregivers. If these targets are not successfully met, caregivers must share cost savings with payers and might be penalized through payments. This reimbursement method ensures that caregivers keep their costs in control. EHR systems and RPM can be adapted to this model through medical informatics.
An 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 by eliminating unnecessary care episodes, increasing overall quality. This encourages a focused approach to key metrics, and RPM solutions can be adjusted accordingly. Practice management solutions can be incorporated within the care givers organization to accommodate this model through advanced medical billing.
Accountable Care Organizations (ACOs)
This popular value-based model is one in which caregivers and healthcare organizations are compensated to improve health outcomes and meet quality metrics. This process can be considerably simplified by applying value-based care with RPM. Value-based healthcare payments take enrolled patients’ accounts and evaluate multiple dimensions of care relevant to peers in the same area.
Success Tips Toward Merging Value-based Care with RPM
- Medical billers and coders can adopt innovative technologies to adapt to these new healthcare payment models. Medical billing management can consider the current medical billing system and make the necessary changes toward reimbursement in healthcare. Integration of RPM 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, hospitals can create medical billing systems that adhere to RPM metrics.
- RPM and billing system integration should also be executed based on HIPAA-compliant solutions in healthcare billing. While choosing the RPM healthcare model, healthcare organizations must look at their specific goals and finalize a model that aligns with them as closely as possible. Healthcare billing and coding challenges must be analyzed and addressed by building customized solutions.
- Healthcare RPM procedures and the chosen value-based care CMS must be directed at keeping costs as low as possible. The model selected should further be aligned with medical claims management and have a proven record of success through pioneer models.
- Billing and reimbursement in healthcare 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.
- Evaluating the patient population is another prerequisite for choosing the ideal payment and RPM healthcare model. Value-based care CMS should be analyzed through patient risk stratification. Ultimately population health management is a means of preventive care.
With high-quality outcomes, superior patient engagements, and a higher volume of patients, the advantages of value-based care and advanced RPM are numerous. Successful implementation will directly translate into lower care costs and reduced medical errors. The healthcare industry is changing, and organizations and caregivers must keep pace with innovative solutions.
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Written by Riken Shah linkedin
Riken's work motto is to help healthcare providers use technological advancements to make healthcare easily accessible to all stakeholders, from providers to patients. Under his leadership and guidance, OSP Labs has successfully developed over 600 customized software solutions for 200+ healthcare clients across continents.