RCM Strategies for Value-Based Care Success

This is where RCM strategies for value-based care success intervene to ask about each contract’s rewards, the patients it covers, and the work your team should do to deserve the payments.

Claims still apply, as do care cost, missing tests, and payment timing.

The point is not to bill for more visits. It is to keep claims clean, record the care made, and recognize opportunities to avoid care gaps that hurt patients and the bottom line.Begin with one contract and assign every task a responsible person and time to complete.

RCM strategies for value-based care success

More visits may not equal more income when a portion of a practice’s revenue depends on cost, care quality, and patient assignment.

Effective value-based care RCM consulting aligns patient records, claims, and contracts to reflect the work completed and qualify the practice for every bonus.

Choose one payer, recognize what it considers incomplete, and address the work behind the gaps.

What Is Value-Based Care RCM?

Revenue cycle management, or RCM, covers the processes for claiming payments for care. In value-based RCM, the practice receives or denies care-based bonuses depending on the contract.

Payment types vary from adding a percentage for enhanced visits to a shared sum for a specific time or care episode.

An accountable care organization, an ACO, is a physician-led entity that coordinates care for a patient population. Participating ACOs in the Medicare Shared Savings Program generate savings when they meet spending and quality benchmarks. 

Claims require attention since clean billing supports the practice navigating value-based payments.

8 RCM Strategies for Value-Based Care Success

1. Turn each contract into a task list

Review the contract’s bonus criteria and create a practice-specific list of measures, patient assignment rules, deadlines, cost expectations, and the chance to be reimbursed if conditions worsen.

Assign each task an owner responsible for completing it by a specific date. When the contract language is unclear, value-based care RCM consulting can advise on the work required.

2. Check coverage and patient lists

Before making an appointment, consider coverage options and review each payer’s patient lists since eligible individuals are not always contracted.

Record updates to the lists with dates and respond to disputes using the payer’s rules. An effective RCM company for accountable care organizations should identify how it evaluates the two lists.

3. Record the care your team provides

Avoid recollection by using field flags for tests, care plans for each measure, and follow-up instructions as the care happens.

Confirm code accuracy according to chart and current practice, and avoid adding diagnoses to raise a patient’s risk score. If the clinical and supporting information is missing or unclear, ask the care provider to explain it.

4. Keep quality work near each visit

Create a care gap task list. Flag patients who need a test, screening, or follow-up and delegate the task to the care team.

Review the inclusion rules for each measure before marking the patient complete to avoid assumptions. A note that a test was discussed is not the same as the procedure being done and may fail the reporting rules.

5. Fix claim errors at the source

Prevent recurring claim errors by grouping similar denials and updating the task list to include correcting entries, approvals, coverage, and notes.

When using an outsourced RCM company for value-based care, ask which team is responsible for these edits. Appeals retrieve lost revenue, but the same error resubmitted next week will not appeal.

6. Link the tools your staff uses

Keep data flowing between practice applications. The value-based care RCM software should integrate with the practice’s patient record application and meet the reporting requirements of each contract.

Test RCM applications for tracking value-based care claims using practice processes and confirm that the program keeps claims, quality reports, and contract payments separate.

7. Forecast payments with care

Avoid spending expected bonuses. Keep the visit cost, fixed payments, and shared savings in separate funding arrangements in the practice’s cash plan.

Test RCM applications for value-based payment models for payment verification and forecasting. Medicare shared savings are finalized yearly after reviewing the quality of care and are not a monthly claim. 

8. Choose partners by evidence

Ask for proof when researching RCM companies for value-based care. Look for experience with the contract type, specific responsibilities, and the ability to produce reports under the same conditions.

The value-based care RCM vendor should reveal expenses, data access, and the ownership of errors. Clarify and confirm before signing the agreement.

Common Challenges in Value-Based RCM and How to Solve Them

Split records create gaps. Choose one source for each report and ensure that patient data matches across applications.

Staff delegates cannot own everything. Assign billing, reporting, and patient outreach to responsible parties with a process for unfinished items.

Tools hide limitations. A value-based care billing software comparison reveals data exchange, reporting, security, support, and overall cost.

Claims do not cover everything. When considering RCM technology for accountable care organizations, confirm that separate tools handle care management and quality reporting.

How Practolytics Supports Value-Based Revenue Cycle Management

Practolytics lists bill review, coding, coverage, compliance auditing, and practice consulting as several of its services. These may support the practice’s billing needs under mixed payment types. 

The company also offers a quality-payment readiness audit that cross-references measures with the chart’s template and reviews the dollar amount. Ask to see which items apply to the practice’s contracts and which responsibilities will remain in-house. 

Get the scope in writing. Confirm who owns the reporting, outreach, and payments.

Performance Indicators of Value-Based RCM to Track

Track income and care. Review the following indicators by payer and contract under the same set of definitions each month:

• First-pass payment rate: Claims paid on the first submission divided by the total reviewed
• Denial rate: Denied claims divided by the total with the reason for the denial
• Days in accounts receivable: The number of days from billing to collecting payment
• Quality measure results: The practice’s performance on each contract’s conditions
• Care-gap closure: The percent of care completed for patients with a gap
• Cost per patient: The practice’s spending for each contract patient compared to the goal
• Payment variance: The difference between the expected and actual contract payments

The focus is not on one indicator. Quick collections do not make up for failed quality measures or an expensive contract.

Conclusion

Improved care requires proof. The practice’s records, reports, and payment reviews should reflect the care delivered and apply to each contract’s requirements.

Begin with one payer and a small task list. Focus on correcting coverage edits, recording care during the visit, and designating someone to complete the reporting tasks.

Keep the practice’s cash plan honest. A potential bonus is not a current resource.

If the practice requires support, ask Practolytics to review the billing processes and discuss the support each contract requires. Agree on the extent of the work, expenses, and outcome measures before beginning the project and confirm that the practice benefits from the changes.

FAQs

1. How long does it take to see results from value-based RCM changes?

There is no standard period since billing may improve before quality bonuses appear. Medicare shared savings are finalized yearly after reviewing the quality of care. 

2. Should I outsource RCM for value-based care?

Outsourcing is an option when staff lacks time or experience with the contract. When comparing vendors, consider cost, responsibilities, and keep care decision-making in-house.

3. What are the biggest RCM challenges in value-based care?

The main issues are split data, missed care, unclear contracts, and delayed payments. Begin with the gaps in the practice’s own records.

4. Can small practices succeed in value-based care?

It is possible with the right contract and support. Review the scope, expense, and financial risk before pursuing a model or an ACO.

5. Which KPIs should practices track under value-based RCM?

Review denial rate, collection speed, quality results, care gaps, patient cost, and payment variances. Select indicators based on the practice’s own contracts.

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