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Advance Possibility

A Holistic Approach to Help Providers Transition to Value-Based Care

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Susan Richards
Director of Risk Adjustment & Coding Education
June 14, 2022

From The Journal of America’s Physician Groups – Spring 2022 Conference Issue by America’s Physician Groups. This article was previously published on issuu.com on June 7, 2022.

“We should work on our process, not the outcome of our processes.” – W. Edwards Deming

The objectives of value-based care are overwhelmingly positive. Who could argue with better outcomes, lower costs, and improved patient and provider experiences? However, while clinicians may agree with these goals in theory, actually achieving them requires developing new processes and addressing technology barriers and infrastructure problems, such as interoperability within an already complex healthcare ecosystem.

The Centers for Medicare & Medicaid Services (CMS) has a goal for 100% of providers to accept downside risk by 2025. With that date quickly approaching, many provider organizations are concerned about the potential revenue impacts. While these organizations are working to adapt to this new payment model, providers are focusing on making the most of their patient encounters. To address these concerns, Episource has identified three key opportunities for organizations to assist providers in the transition to value-based care delivery:

  1. Before the visit has occurred
  2. After the visit, but before the claim has been submitted
  3. On an ongoing basis

By implementing a holistic approach that includes strategies targeting each of these areas, provider organizations can realize savings, optimize care, alleviate administrative burden, and most importantly, give more value to patients.

Before the Visit: Preparing for the Patient Encounter

To ensure the highest quality of care, clinicians need context on their patients before the visit so they can adequately prepare to address any health concerns or chronic conditions. While electronic medical records (EMRs) have helped optimize the management of patient data, moving this data between systems is still a challenge. Initiatives are underway to build a system architecture that will allow all stakeholders to easily access, analyze, and share this information. 1

With such a system in place, clinicians could access a targeted, pre-visit summary that synthesizes clinical information, enabling them to focus on the most pressing issues. For example, proprietary software that integrates with EMRs could review patient information and highlight conditions that warrant further review. This kind of targeted summary can save providers valuable time, allowing them to focus on clinical care rather than administrative work.

Pre-visit prep is especially important for patients with chronic illnesses who have not kept scheduled appointments due to the pandemic, healthcare costs, or other reasons. It can increase the value of the encounter when they do show up for an overdue visit, resulting in enhanced clinical interventions and better quality scores.

After the Visit: Streamlining Clinical Documentation

Clinical documentation enhancement and coding reviews happen between the time the doctor writes the encounter note and the claim goes out the door. Most groups that employ these processes are focused on ensuring that high-cost procedures and inpatient stays are properly coded.

“Providers spend 27% of their work time on direct patient interactions and 49% on EMR documentation.”

However, provider groups should also be using these same processes to validate patient health status. This will allow providers to better match their services to a patient’s needs in near-real time, as chart reconciliation may not be completed until up to 18 months after the claim submission.

The vast majority of outpatient practices rely on clinicians to code their own encounters. In a fee-for-service world, where doctors are paid for services that tend to be the same from day to day, this is not as big of a burden. However, in a value-based care world, the focus is more on communicating patient health status via coding — and there are thousands of codes for physicians to choose from that may not be intuitive from a clinical perspective.

This unwieldy documentation process is one the biggest sources of frustration and administrative stress for providers today. Did you know that providers spend 27% of their work time on direct patient interactions and about 49% on EMR documentation? What’s more, because coding is a translation tool rather than a clinical construct, we’ve found that providers typically perform risk adjustment coding to 54% accuracy on their first pass — versus 98% accuracy when performed by an expert coder.

Partnering with an expert coding vendor can alleviate this burden and ensure greater accuracy in claims and clinical documentation prior to submission. Partnering with a vendor that uses a combination of natural language processing (NLP) and human coders can improve accuracy even further by assessing whether documentation has MEAT (monitored, evaluated, assessed/addressed, and treated). 2

This method provides clinicians with a better understanding of population health, as well as how different member cohorts are doing. Not only will this approach benefit patients, it will also likely improve value-based payments and mitigate audit risk, which is growing in importance due to scrutiny from the Office of Inspector General and CMS.

Ongoing Basis: Quality Reporting and Data Analytics

Population health management is a top priority for provider organizations. Partnering with a vendor that can drill down into patient data with advanced analytics can help providers highlight population health opportunities and identify high-need, high-acuity patients.

Armed with this knowledge, providers can create targeted care plans that address issues at the root, helping ensure all patients have access to the care they need. This will lead to improved clinical outcomes, a better patient experience, and reduced administrative burden.

An End-to-End Partner

While some technology solutions offer piecemeal solutions to certain infrastructure challenges, many clinicians lack the time or resources to implement them. Partnering with a technology vendor that understands how to strategically apply a wide range of holistic, integrated strategies across the entire revenue lifecycle will help providers realize savings, alleviate administrative burden, and ensure all patients have equitable access to high-quality care — the core tenets of value-based care.


1 Jercich K. Interoperability progress but still ‘much to be desired,’ says KLAS-CHIME report. Healthcare IT News. https://www. healthcareitnews.com/news/interoperability-progress-still-much-bedesired-says-klas-chime-report.

2 Dick M. Include MEAT in your risk adjustment documentation. AAPC. https://www.aapc.com/blog/41212-include-meat-in-your-riskadjustment-documentation/.

3 Understanding your members through health risk assessments. Episource. https://www.episource.com/solutions/clinical-servicessolutions/