Trish Wharton, RHIA
Vice President, Strategic Accounts, Streamline Health
Let’s face it. If you look past the countless providers making a positive impact on patients’ lives every day, healthcare is essentially a business. And in order to serve its core mission of delivering quality care to its community, that business needs to be financially viable. Successful hospitals are those that generate adequate revenue to cover expenses as well as invest in the latest technology, market their services to patients, and more.
Maximizing revenue: then and now
Under fee-for-service payer contracts, gauging financial performance has been relatively straightforward. A coding manager could safely assume their hospital was optimizing revenue as long as coders submitted claims in a timely manner and minimized denials as much as possible. Under these types of contracts, HIM staff often maximized revenue by:
- Applying payer-specific guidelines
- Capturing all relevant procedures, services, and charges
- Monitoring denial trends and taking proactive steps to mitigate any problems
- Obtaining coding and documentation specificity
Now, with the ongoing transition to value-based payment models, there’s no guarantee that coding accuracy automatically equates to increased reimbursement. Quality indicators are now playing a greater role in reimbursement, which complicates matters for HIM and coding managers.
Linking quality to payment
Under value-based payment models, commercial payers as well as Medicare and Medicaid want to know more about the quality of the care that’s rendered before they dole out payment. Payers assess quality through various measures that providers report in addition to ICD-10-CM and PCS codes. According to CMS, quality measures are “tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include effective, safe, efficient, patient-centered, equitable, and timely care.”