Medforce Blog

Back Office Implications of HHS Goals for Quality-Value Based Payments

February 26, 2015

Category: General

At the end of January, the Department of Health and Human Services (HHS) announced it set a goal that by 2016, 85% of provider payments under Medicare’s fee-for-service system will be based on the quality or value of care rather than the volume. In that same time frame, the agency hopes to be making 30% of its payments through alternative payment models like Accountable Care Organizations (ACOs), where care providers work together toward better long term outcomes for patients. [Source: HHS]. Enabling better patient outcomes, decreasing or sharing costs among providers, mutual participation in shared savings, and ensuring the wisest allocation of Medicare dollars are among the oft-cited benefits of these programs and goals.

But along with the clear vision for value based healthcare, there remains the question ofhow the transformation will take place. One of the biggest questions in our mind is: How will new protocols for requesting, supporting and fulfilling quality-based payments impact the operational processes of providers? As pioneering ACOs and other value-based care providers (re)organize their systems to manage the care of patients, the implications of these new standards on the back office has yet to fully be explored.

What will it mean from a practical standpoint for providers? How will the billing and reimbursement process change? How will the revenue cycle be affected in both the short term and long term? What kind of new documentation standards will be created? How will this affect audits and appeals? Where do integral members of the continuum of care that may not be physician based (e.g. Pharmacies and DME and HME providers) fit into the picture?

The quality-based reimbursement requirements will be new to many and likely to be stringent, necessitating changes to internal processes for providers to secure payment. The documentation rules are going to change, as proof-of-value goes beyond proof-of-service. Will there be a need to document what didn’t happen (e.g. no hospital readmission) as well as what did? And, if so, how long could that delay payment from the time of service, and how will audit requirements change in multi-provider settings?

A lot remains unknown and will only be unraveled with time. There are, however, clear truths that we know will remain the same:

  • Technology remains crucial to success. These payment goals will only be attainable through the integration of people, processes and data. Providers must embrace technology to allow for seamless care coordination, sharing of information, and integrated reporting.  Technology is the enabler that will allow the full benefits of value-based care to succeed.
  • Accessibility is vital. Flexible, adaptable and customizable electronic file and document management will continue to be a critical underpinning of successful operations. It seems reasonable to assume that documentation efforts will increase from both volume and need for coordination. Easy accessibility – with minimal clicks  - to your files and also your partners’ will be key.
  • Access rights management will become more important. As documentation and contractual requirements increase, the reimbursement process has the potential to become more complex. To streamline processes and eliminate clutter for your administrative and billing staff (as well as maintain appropriate information privacy) a robust access rights management system is necessary.
  • Standardization will rise in importance within individual providers as well as within networks. Business process management and workflow software can ease the burden of coordinating delivery of care in addition to any/all aspects of running your organization, including Intake, HR, Billing, Claims management, and more. Once a process is standardized, part or all of it can be automated, keeping complex processes on time and on task.
  • Integrations will be obligatory. All-in-one will cease to be an effective way to manage, as various providers will need to bring together individual systems effortlessly. Easy and standard integration with a myriad of other healthcare related software will be the norm, including various billing programs, practice management, EHR, document imaging, and delivery verification.  Software that can easily adapt, interface, integrate and customize will be the technology of choice.


What are your questions and concerns regarding the shift to Medicare payments based on quality of care? What are you doing now to ready your organization for these changes? Leave us a comment and let us know what you’re thinking.




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