How to Get Managed Care Companies to Pay for Your Practice’s Improvements

managed care moneyBy: Valerie Shahriari, via Healthcare Reimbursement Blog

Florida’s providers are buzzing with questions about value based care, asking why now? Is it a fad? Will it really ever be a widespread form of payment? Why does Florida seem farther behind the value based curve than other markets?

While there are more aggressive markets in other parts of the country, the bottom line is this: CMS changes are coming and they will not be stopped.  The government has invested too much money to turn around at this point.  Here are just a few examples of why:

  • The CMS Value Based Program with hospitals is already implemented;
  • Center for Medicare and Medicaid Innovation is piloting NUMEROUS programs covering many physician specialties
  • CMS expanded the Medicare Shared Savings Program to 3 tracks.
  • A new Merit-Based Incentive Payment for Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be apply to payments for services furnished in 2019.

The train has left the station. Providers will now shift from fee for service to value based payments with CMS.  To be successful and still have a profitable business, clinical integration and quality improvements will need to be implemented to improve your practice whether you are hospital based or office based AND whether you are employed by a hospital or in private practice. These changes will be implemented for all of your patients as you will not distinguish in your level of service between patients with managed care as the payor rather than CMS.  This essentially means that managed care payors will reap the benefits of these improvements in your practice.  If you do not have a value based contract in place with the managed care payors they will not be sharing one dime with you.  They will reap the benefits of your improvements AND keep the money!  And by the time you get around to a managed care contract that is value based, the shared savings opportunities will be less than if you began those discussions now. 

So what are the “improvements” in your practice that will be required for you to be successful in this new payor world?  In the previous article titled “Volume is no longer King”, we discussed determining the financial risk that your practice can take on and finalizing the quality metrics that best suits your practice.  The next step is Assessments and Implementation Strategies.

Data that is truly informative will be essential.  Assessing your baseline for those quality metrics that you have finalized is the first step.  The question to ask is what your performance for each quality metric has been for the past 24 months and where it is currently.  This is necessary as you want to evaluate your current performance to see if it is a consistent number/evaluation or a blip in the results.

Once a baseline is determined, what can you do to improve that number?  Gathering your office staff for their input is a great place to start.  In the quality world, we call that going to the Gemba.  This means that you go to the front line of your office staff.  They have great ideas on how things can be improved.  They see these processes in action every day.  Take down all suggestions and vet them with a smaller group.  Put together an action plan where you identify start and end dates for each item so that you can pilot and measure what works and what doesn’t make an impact on your data.  It will likely take several rounds assessing, planning, implementing and evaluating to get your data moving in the right direction.

Ensure this opportunity for success is included in your contracts with managed care payors.  By taking the lead, you will have the opportunity to share in your successes and not give away this information for free.

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