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The role of a medical billing services company in supporting value-based care

Care in Healthcare can be approached as Fee-Based Service and Value-Based Service. Fee-Based Service has been in practice for ages while the latter became an improvised approach starting in the 20th century. Yet, the term Value-Based care was coined in 2006 by Porter and Teisberg in their seminar work, “Redefining Healthcare”. In short, the definition would stand for, “High quality, efficient and patient-centered care aiming towards better patient outcomes and experiences”.

The conscious starting point for Value Based Care with the Affordable Care Act (ACA), 2010 which strived to provide affordable healthcare insurance. The goal is to have the entire system comply with VBC by 2030 and already more than 13 million practices have complied or in the process of moving towards VBC as per last year’s data. As a medical billing company our questions would be, “What would it mean for us?” and “How should we aid our clients to align with the stated VBC?”. To obtain the answer, discussing the function of a VBC-inclined practice would be the first step.

To know this, let’s discuss briefly how a typical VBC-inclined practice would function. For ages, the bill for healthcare has been based on the number or the duration of services. This approach led to huge bills, lesser concentration on patient experience, and positive outcomes as the focus was never on the quality of the services provided. The V in VBC stands for the Value, in other words, the quality of services leading to a better patient experience also implies controlled costs.

In short, VBC proposes a new way of billing for the services provided based on the value. If a VBC-based bill is billed by a Third-party Medical Billing Company in the already existing norm, a denial is unavoidable. Is there going to be that much of a difference? According to the latest Harvard Medical School article which mentions that value-based payment methods will be completely different from traditional fee-for-service methods, and this would only work if everyone involved with billing understood the change and was trained.

With being said, challenges are unavoidable in adapting or getting used to any relatively new approach, here as well it can be rendered its own list. First and foremost, the relative newness speaks for a lack of touchstone. Referring to the past data or history would not be an option anymore resulting in multifold of back work, thought processes, and resources. Secondly, since the bill would be proportionate to the value of services and not the number of services, providers would have a reduction of revenue, and a medical billing company which gets a cut in the revenue, would also see a reduction in revenue collection as it is just an obvious butterfly effect. Finally, as per the earlier mention, the essential element to have a smoother transition is Training, which requires a clear budget. If there is a gap in training the personnel involved, a catastrophe becomes inevitable and isn’t prevention always better than cure?

Compliance with VBC applies to the healthcare providers, but that is also indirectly the third-party billers ‘s aid. For medical billing services in the context of Value-Based Care, providing thorough support in the areas of documentation optimization, compliance, technology infrastructure, analytical insights, and switching to alternative payment plans is essential. These steps help healthcare providers successfully shift to value-based reimbursement models while also improving operational efficiency and financial stability.

First off, by streamlining documentation, a third-party billing provider is essential to a Value-Based Care (VBC) client’s support. In contrast to conventional compensation techniques, VBC demands accurate and thorough documentation to guarantee smooth claims processing. Compliance support is similarly important since, considering the new requirements that are specific to VBCs, compliance with regulatory standards protects clients’ financial standing and reputation. To efficiently satisfy VBC expectations, it is imperative to invest in a strong technological infrastructure, which includes Electronic Health Record (EHR). A list of infrastructures has been provided that is typically sought after for investment by Medical Billing Service Companies.

• EHR software and platforms
• Data sharing and collaborative solutions
• Tools that help in seamless communication between billers and healthcare providers
• AI-based solutions to intelligently automate billing

Additionally, analytical support—which includes analysis at several stages—is essential for medical billing organizations. They use predictive analysis to foresee future trends and regulatory changes, periodic mid-way analysis to identify billing process bottlenecks and opportunities for improvement, and study of pre-VBC data to create transition strategies.

Another crucial component is making the switch to alternative payment models, with bundled payments, pay-for-performance, and Accountable Care Organizations (ACOs) being the focus starting in 2024. To provide the best possible reimbursement methods for customers, medical billing services must navigate through a variety of payment models, such as the Capitated Risk Sharing Model (CRSM), which incorporates shared financial risk among healthcare providers, payers, and patients.

Change is constant and adapting to it is not always easy but essential. Adapting and working on the VBC compliance is the only highway option for any part of the health care system. Hence, the valuable takeaway is looking into the areas that require adaptation to comply with the VBC approach, and investing towards the goal would be the wisest choice for any medical billing company as by 2030, the entire healthcare is predicted to have accustomed to VBC.