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Laying the Groundwork for Pay-for-Performance

As the dynamics of healthcare payment models change, practices should continue to be mindful of the pay-for-performance model. This reimbursement model represents a departure from traditional fee-for-service models in that pay-for-performance is based on the outcomes of care rather than the delivery of care. In other words, physicians and practices receive financial incentives for achieving measurable benchmarks in safety, quality, patient satisfaction and efficiency as opposed to receiving payments for delivering particular services. Pay-for-performance programs are typically based in part on quantitative measures, which may include process and outcomes measures as well as patient satisfaction scores.

While these programs all work toward the goal of better outcomes for patients, not all pay-for-performance programs are the same. Practices should perform their due diligence before agreeing to participate in this type of program. According to MGMA-ACMPE, the goal of pay-for-performance programs should be to improve healthcare quality and safety. Below are a few areas to evaluate to help your practice implement a successful pay-for-performance model.

Look at Eligibility Verification

To lay the groundwork for pay-for-performance, practices should review both their care processes and their business functions to ensure they deliver optimal care to patients in the most efficient manner. One area warranting examination is eligibility verification. By streamlining this process and verifying eligibility before a patient arrives for a visit, practices can proactively identify any patients eligible for a pay-for-performance payment model. Knowing how a patient’s care will be reimbursed can help practices design and bill for care appropriately. This knowledge will also reduce rejections and denials down the line.

Examine Denials Management

As practices start using pay-for-performance models, there may be some initial issues with rejections and denials as both payers and providers become accustomed to the new approach to reimbursement. Having a strong denial management process is essential to not only respond effectively to any denials that occur, but also to prevent such denials over time. A thorough denial management process should identify patterns of concern to target and address.

Support Strong Reporting

Finally, to reap the most benefit from pay-for-performance programs, practices must be able to clearly demonstrate performance. Solid reporting solutions can identify opportunities for improving performance and also communicate effectively about that performance. Leveraging such solutions can help a practice receive comprehensive and appropriate reimbursement.

It’s important to remember that all pay-for-performance programs should be voluntary, involve evidence-based performance measures, be risk adjusted and reward the use of electronic health records. They also shouldn’t be financially burdensome to implement within your practice. Keeping these qualities in mind when choosing a program to participate in will help ensure success. What steps has your practice taken to implement successful pay-for-performance programs?