Looking longer term, MGMA’s Ballou-Nelson says that as value-based contracts become the norm, practices need to ensure they thoroughly understand each contract and what metrics will be used to measure them. “You don’t want to sign something and find out later you don’t have the resources or capability to do what’s in the contract,” she says. “And if you don’t know how you’re doing on a metric they’re going to score you on, you’d better hold off getting into a downside risk contract until you have a better handle on your own data.”
Coding remains crucial
The spread of value-based and risk-bearing contracts also means that practices need to redouble their focus on thorough and accurate coding and documentation. That’s especially important when it comes to risk-adjustment (also known as hierarchical condition category) coding, says Susan Whitney, senior content manager at MGMA.
Without HCC coding, Whitney explains, payers may not get an accurate profile of a practice’s patient base, including factors such as age and morbidity that might make its costs higher than similar practices with whom the payer contracts. That, in turn, could put any shared savings at risk. “If patients aren’t accurately pictured, the practice may well lose out on some money,” she says.
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Whitney cites the example of a patient complaining of abdominal pain. “Coders know the practice will get paid for the office visit based just on that [abdominal pain],” she notes. “But if the patient also has diabetes or morbid obesity and you tack those diagnoses on, their risk-adjustment score goes higher, and payers start looking at that practice differently.”
The adoption of the ICD-10 code enables payers to obtain far more detailed information about patients’ conditions and diagnoses, Whitney says, and compare them to the practice’s costs. That’s why it’s important for practices to code as specifically as possible, and doctors to provide the documentation to back up the codes.
“A lot of practices haven’t understood how all these factors tie together,” Whitney says. “Now they need to begin connecting the dots so they can collect everything they’re owed.”