The journey to value: From finances to patient access, get your house in order for fee-for-value

Health care is driven by the wants and needs of the market. Consumers want better transparency and value at the same time governments, payers and employers are trying to keep costs down and stimulate quality improvement. This means more pressure on providers to deliver efficient care while not passing on costs to patients.

But, making any change requires money, and providers are short on cash. Government regulations, economic ups and downs and declining reimbursements have put the squeeze on provider budgets.

Rather than risk being left behind while the market moves forward, provider organizations can optimize financial performance through improvements in patient access, medical necessity, coding, documentation and reimbursement.

The first two critical areas — patient access and medical necessity — can, with the right advancements, improve claims acceptance and cash flow, not to mention enhance the patient experience. A streamlined scheduling and registration flow can help patients and their families begin their care experience on a positive note. And by embracing new systems for coding, documentation and other functions, provider organizations can reduce inefficiencies in utilization, patient care and workflow.

Even as the industry shifts from fee-for-service to fee-for-value, documentation and coding will remain at the core of reimbursement. There are two distinct areas where technology can play a vital role in improving the accuracy, productivity and efficiency of coding and documentation.

  • Improve revenue cycle productivity with CAC — Computer-assisted coding (CAC) solutions help speed up the coding process and make it more accurate. Most CAC applications use a natural language processing (NLP) engine to automatically analyze electronic documentation. Such analysis is the key to CAC’s effectiveness. After analyzing documentation, the NLP engine serves up a list of potential codes to a coder, who then validates the recommendations.An NLP engine’s proficiency at documentation analysis is key to helping hospitals save money. The speed with which an NLP engine can accurately review patient charts will help improve productivity and speed up cash flow. And since quality coders are in short supply, improved productivity from quicker documentation review and subsequent suggestion of codes can help coding departments do more with less.
  • Improve coding and billing accuracy with automated CDI — A technology similar to CAC also promises to improve revenue cycle productivity: automated clinical documentation improvement (CDI). By automating patient medical record review using NLP, automated CDI can review hundreds of cases per day and identify those that have a high probability for documentation improvement. This allows CDI specialists to prioritize the cases on which they work and minimizes the number of queries a physician needs to review to determine clinical relevance.

In addition, there’s a new-found benefit of the coding/quality connection. An Optum study found that accurate, complete coding was a factor in the quality of care provided to patients. Chronic disease patients without a coded diagnosis — for example, diabetes patients whose medical claims didn’t include a coded diabetes diagnosis — were found to be generally sicker, using more acute care services and fewer ambulatory services than patients with a coded diagnosis.

IJourney White P apern our next post, we’ll discuss how to address reimbursement issues and begin preparations for the journey from volume to value.

More information can be found in our latest white paper: The journey from providing care to managing health.


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