Topic: Risk-Based Contracts & Cost Performance

EFS Risk-Based Contracts: total cost of care, RAF and value-based performance.

Medicaid Coverage Risk Calculator

Written on August 11, 2026.

Medicaid Coverage Risk Calculator

What Could Medicaid Coverage Loss Cost Your Health Center?

Estimate the patients, encounters, and revenue that could be exposed to renewal-process disruption and new Medicaid community engagement requirements. Start with the national benchmark or choose your state, then adjust the assumptions to reflect your health center.

CMS renewal benchmark: July 2024 Medicaid & CHIP renewal outcomes. Community-engagement scenarios are model assumptions, not forecasts.

Please complete this short form to receive an email with a personalized link to the report.

Your Medicaid population

State benchmarkNational procedural termination benchmark: 10.8% Annual Medicaid patients servedUnique Medicaid patients seen annually

Encounter & revenue data

Annual Medicaid outpatient encountersUse annual encounter counts Net revenue per outpatient encounter

Use net patient revenue, not gross charges

Projection

Community-engagement scenario

23% loss among patients modeled as potentially subject to the requirement; historical benchmark from Arkansas, used only as a sensitivity assumption.

Model assumptions

Estimated share potentially subject to community engagement

Illustrative default. Adjust for your adult-group and exempt population mix.Overlap between renewal and community-engagement risk

Reduces double counting when the same patient appears in both risk pools.Average renewal-process coverage gap

months

Average community-engagement coverage gap

months

Estimated revenue exposure

12-month directional exposure

Annual patients potentially at risk0

Estimated encounters exposed over selected period0

Renewal-process benchmark10.8%

Community-engagement assumption23%

Renewal-process risk pool0

Community-engagement risk pool0

Estimated overlap removed0

Coverage loss becomes an activation problem when eligible patients do not understand, document, or complete the next required step.

Guideway helps health centers identify risk, activate patients, and drive enrollment, documentation, and recertification through completion.

Sources and assumptions: CMS Medicaid & CHIP July 2024 renewal outcomes; CMS community engagement rule; CBO Arkansas historical benchmark. Community-engagement scenarios and advanced assumptions are directional model inputs, not forecasts.

Directional estimate only. This calculator does not provide actuarial, legal, regulatory, reimbursement, or CMS-certified guidance. Validate assumptions against your organization’s own patient, financial, and state implementation data.

Risk Adjustment Gaps in Chronic Care Management

Written on April 1, 2026.

CHRONIC CARE MANAGEMENT

Your Risk Scores Don’t Reflect the Patients You’re Treating

Every undocumented chronic condition lowers your risk adjustment scores, shrinks your capitated payments, and makes your patient panel look healthier than it actually is. The gap between your actual patient acuity and what your data shows is costing you real money.

THE CHALLENGE

Your RAF Scores Are Artificially Low

Risk Adjustment Factor (RAF) scores drive capitated payment rates across Medicare Advantage, ACO, and other value based contracts. Higher acuity patients generate higher payments because they cost more to treat. That math only works when your documentation captures the full clinical picture.

Most organizations know their RAF coding could be more complete. Chronic conditions go undocumented or under specified. ICD-10 Z codes that should be captured during care encounters get missed because there isn’t enough time during the visit, the right questions don’t get asked, or the data simply doesn’t make it into the record.

The result: your risk scores are artificially low. Your payments don’t reflect the actual complexity of your patient population. And the revenue you’re losing isn’t a one time hit. It compounds year over year as incomplete data carries forward into future payment calculations.

ROOT CAUSE

You’re Missing the Most Consistent Touchpoint You Have

The documentation gap isn’t just about coding accuracy. It’s about missing the most consistent touchpoint you have with your highest acuity patients.

CCM calls happen monthly. Office visits happen a few times a year.

For patients with multiple chronic conditions, the monthly CCM outreach is often the most frequent clinical touchpoint they have. Every one of those calls is an opportunity to capture updated diagnoses, document condition progression, and ensure the medical record reflects reality. When your CCM program isn’t running, or when it’s running without RAF documentation workflows built in, you’re missing 12 opportunities per patient per year to get your data right.
Incomplete risk data distorts your entire population health picture.

It’s not just the payment impact. When your data shows a healthier population than you actually serve, your care management programs are built on flawed assumptions. You understaff for actual acuity. You underfund interventions. And you’re surprised when outcomes don’t match your models.
The gap widens as value based contracts expand.

CMS and commercial payers are steadily shifting toward risk adjusted payment models. Every undocumented HCC code today means lower baseline payments tomorrow. Organizations that build RAF capture into their CCM workflows now are compounding their advantage. Organizations that wait are compounding their losses.

OUR APPROACH

RAF Documentation Built Into Every Touchpoint

Our CCM program builds RAF documentation into every patient touchpoint. It’s not a separate workflow or an add on. It’s embedded in the call structure.

Complete ICD-10 Z code capture at every interaction

Our clinical specialists use structured protocols that prompt for complete condition documentation during every CCM call. No codes left on the table.
Your medical record gets updated, not a separate database

We work directly in your EHR. Documentation captured during CCM outreach flows into the patient’s permanent record, available to every clinician who treats them.
Evidence based, condition specific workflows

Our protocols are designed around the chronic conditions your population carries. Diabetes, COPD, CHF, hypertension, and complex comorbidities each have tailored documentation pathways.
Audit ready from day one

HIPAA compliant, SOC 2 certified, NIST compliant. Every documented encounter stands up to scrutiny.

See our full Chronic Care Management approach

RELATED CHALLENGES

CCM reimbursement going uncaptured alongside the RAF gap

The same touchpoints that would capture RAF data would also generate CCM billing revenue.

Go Deeper
Open quality gaps that the same undocumented patients are driving

Incomplete documentation and open quality measures compound each other.

Go Deeper

PROVEN AT SCALE

Complete documentation at every touchpoint

We capture the full clinical picture so your risk scores reflect reality and your payments match your patient acuity.

99.4%

Quality KPI pass rate

HIPAA

SOC 2 & NIST compliant and audit ready

EHR

Integrated documentation at every touchpoint

Stop leaving risk adjustment revenue on the table

See how a CCM program with built in RAF documentation can capture the revenue your patient acuity supports.

Schedule a Consultation

Back to Chronic Care Management Overview

Revenue Capture in Chronic Care Management

Written on April 1, 2026.

CHRONIC CARE MANAGEMENT

The CCM Revenue Sitting in Your Patient Panel

CMS pays $64.02 per patient per month for chronic care management. Most organizations capture a fraction of what they’re eligible for. The math is simple. The execution is where it breaks down.

THE CHALLENGE

Your CCM Revenue Is Theoretical Until Someone Captures It

You know CCM is reimbursable. You may have even tried to stand up a program. But the numbers never matched the projections.

Eligible patients go unidentified. Enrollment stalls after the first quarter. Monthly outreach falls behind because clinical staff get pulled into higher priority work. Documentation gaps make claims vulnerable to audit. And the revenue that looked so promising on a slide deck stays theoretical.

This isn’t a failure of intent. It’s a failure of bandwidth. Your team has the clinical capability to deliver CCM. They don’t have the operational capacity to sustain it at the scale your patient panel demands.

CPT 99490 pays $64.02 for 20 minutes of CCM service per patient per month. CPT 99439 adds $47.44 for each additional 20 minutes, billable up to twice per patient per month.

At 250 patients on CPT 99490 alone: $16,005 per month. $192,060 per year.

Add 99439 billing for even a portion of those patients and the total climbs significantly. This is revenue CMS is ready to pay. The question is whether your organization can operationally capture it.

ROOT CAUSE

The Revenue Gap Is the Symptom. The Deeper Issue Is What Uncaptured CCM Means for Your Entire Chronic Population.

The revenue gap is the symptom. The deeper issue is what uncaptured CCM means for your entire chronic population.

Every month without CCM outreach is a month of unmanaged chronic disease.

Patients with diabetes, COPD, heart failure, and other complex conditions don’t pause their disease progression because your team is too busy to call them. They miss medication adjustments. They skip follow up labs. They avoid specialist referrals they don’t understand. By the time they show up in your system again, it’s often in the ED.
Uncaptured CCM also means uncaptured risk adjustment data.

Every CCM touchpoint is an opportunity to document ICD-10 Z codes and update the clinical picture. When those touchpoints don’t happen, your risk scores stay artificially low, your capitated payments shrink, and you lose revenue across every value based contract. This compounds. Year over year, your organization’s risk profile drifts further from reality.
The competitive exposure is growing.

CMS has consistently increased CCM payment rates since the program launched. Organizations that build CCM infrastructure now are capturing revenue and strengthening patient relationships. Organizations that wait are watching patients with multiple chronic conditions receive better care management from competitors who made the investment.

OUR APPROACH

We Capture the CCM Revenue Your Panel Supports

We operate as a turnkey extension of your clinical team, handling the full CCM lifecycle from eligibility identification through billing submission.

Eligibility analysis and enrollment

We identify CCM eligible patients in your panel and manage the enrollment process, including patient consent and care plan initiation.
Structured monthly outreach

Our clinical specialists deliver condition specific, evidence based outreach every month. Every call follows structured workflows designed to activate patients, not just check a documentation box.
Complete billing capture

We manage documentation for CPT 99490 and 99439, ensuring every billable minute is captured, compliant, and audit ready.
White labeled under your brand

Patients never know they’re talking to an external team. Your brand, your protocols, your escalation paths.
EHR integrated

We document directly in your EHR. No separate systems, no reconciliation, no data gaps.

See our full Chronic Care Management approach

RELATED CHALLENGES

Clinical staff stretched too thin to sustain monthly outreach

Your team can’t add CCM on top of existing workloads without something breaking.

Go Deeper
Incomplete risk adjustment documentation compounding revenue loss

Every missed CCM touchpoint is a missed opportunity to capture RAF data.

Go Deeper
Open quality gaps dragging payer performance scores

The same patients whose CCM isn’t happening are the ones driving your quality measure gaps.

Go Deeper

PROVEN AT SCALE

Built to capture every billable minute

We manage the full CCM billing lifecycle so your organization captures the revenue your patient panel supports.

$192,060

Projected annual reimbursement at 250 patients (CPT 99490)

$47.44

Additional per patient per month (CPT 99439, up to 2x/month)

99.4%

Quality KPI pass rate

HIPAA

SOC 2 & NIST compliant

See the CCM revenue in your patient panel

We’ll show you the reimbursement opportunity sitting in your existing chronic patient population and how to capture it without adding headcount.

Schedule a Consultation

Back to Chronic Care Management Overview

Care Management

Written on March 30, 2026.

The Challenge

Your Problem

Medicare’s care management programs were designed to keep patients healthier between visits, reduce avoidable utilization, and generate new revenue for the organizations delivering the care. The economics are clear. The execution is where it falls apart.

You can’t staff five programs with one team

CCM, RPM, PCM, AWV, and TCM each have their own billing codes, documentation requirements, eligibility criteria, and outreach cadences. Building internal capacity across all five means hiring, training, and retaining multiple specialized roles. Most organizations pick one program, run it partially, and leave the rest on the table.

Staffing and bandwidth

Siloed programs create siloed outcomes

When CCM and RPM don’t talk to each other, patients get duplicate calls, conflicting instructions, and fragmented care. When AWV and TCM operate independently, the data captured in one program never informs the other. Your patients experience the silos even if your org chart says they shouldn’t.

Connected care management

Revenue leaks at every seam

Every care management touchpoint is a billing opportunity, a risk adjustment documentation opportunity, and a quality gap closure opportunity. When programs run separately or don’t run at all, you miss billable minutes, leave RAF codes undocumented, and watch quality measures stay open.

Revenue capture math

Root Cause

As Healthcare Experts, We See the Deeper Problem

The real problem isn’t that care management is hard to execute. It’s that the model most organizations use was never designed to produce outcomes.

Care management without activation is just documentation

Compliance vs. Activation

Most programs follow the same pattern: call the patient, ask how they’re doing, document the conversation, bill the code. The call produces a compliant record. It doesn’t produce a completed referral, a filled prescription, or a scheduled lab. The patient hangs up and navigates alone.

Follow through failure
Five programs running independently cost more than five programs running together

Duplicated Infrastructure

Each program has its own enrollment workflow, documentation template, QA process, and reporting cadence. When they’re separate operations, you duplicate infrastructure, train multiple teams, and create gaps between handoffs.

Operational efficiency
Your highest acuity patients carry the most uncaptured value

Uncaptured Value

Patients with multiple chronic conditions, recent hospitalizations, and complex social needs are eligible for multiple care management programs simultaneously. They’re also the patients with the most open quality gaps, the most incomplete risk adjustment data, and the highest avoidable utilization risk.

Risk adjustment gaps

Our Approach

One team. One integration. Five activated programs.

We operate as a dedicated extension of your clinical team, delivering all five CMS reimbursable care management programs through a single operational infrastructure. Same specialists. Same EHR integration. Same activation methodology. No silos. No gaps between programs.

Activation psychology at every touchpoint

Our specialists are trained in the Motivational Patient Guidance framework. Nine behavioral science techniques that turn care management calls into completed next steps. Not compliance. Activation.
Single EHR integration, five programs

We document directly in your EHR across CCM, RPM, PCM, AWV, and TCM. One integration. One audit trail. Complete data flowing to every clinician who treats the patient.
White labeled under your brand

Patients experience our team as your team. Consistent voice, your protocols, your escalation paths. No visible seams between programs or between our team and yours.
Connected patient journeys, not siloed programs

A patient who discharges from the hospital starts TCM. When the 30 day window closes, they transition to CCM. Their remote monitoring data from RPM informs every CCM call. One relationship. Five revenue streams.
Full billing capture across all codes

We manage eligibility, enrollment, outreach, documentation, and billing across every applicable CPT code. No billable minutes left uncaptured.

Check-ins aren’t enough

Five Reimbursable Programs

Connected care management across every stage of the patient journey

We deliver all five CMS reimbursable care management programs through a single team and a single EHR integration.

Chronic Care Management (CCM)

For patients with two or more chronic conditions. Monthly activation driven outreach, condition specific protocols, complete billing capture (CPT 99490, 99439), and RAF documentation at every touchpoint. The foundation of connected care management.

$64.02 per patient per month (CPT 99490) | $47.44 each additional 20 min (CPT 99439, up to 2x/month)

Explore Chronic Care Management
Remote Patient Management (RPM)

For patients using remote monitoring devices. We provide the activation layer between device data and patient outcomes. Dedicated specialists respond to alerts, conduct proactive outreach for non transmitters, and convert readings into completed care actions.

Explore Remote Patient Management

Principal Care Management (PCM)

Focused care coordination for patients with a single high complexity chronic condition. Same activation approach, targeted to a narrower clinical scope.

Explore PCM
Annual Wellness Visits (AWV)

Proactive scheduling, completion, and documentation of Medicare annual wellness visits. Every visit becomes an activation touchpoint for care gap closure and risk adjustment documentation.

Explore AWV
Transitional Care Management (TCM)

Post discharge outreach during the critical 30 day window. We reach patients quickly after discharge, resolve medication confusion, schedule follow ups, and ensure they complete their transition.

Explore TCM

Connected Activation

The patient journey, not the billing code, drives the model

A patient with heart failure and diabetes is discharged from the hospital. Here’s how our connected infrastructure activates them across every stage.

1

Days 1 – 2

TCM Outreach

Confirms discharge instructions, medications, and follow up appointments. Resolves transportation and access barriers during the call.
2

Days 3–30

TCM + RPM

Ongoing TCM management. Remote monitoring tracks weight, blood pressure, and blood glucose daily. When readings spike, our team contacts the patient before it becomes an ED visit.
3

Day 31+

CCM + RPM

TCM transitions to CCM. Monthly activation calls continue. RPM data informs every conversation. Barriers are resolved. Next steps are completed.
4

Annual

AWV

The annual wellness visit captures updated ICD-10 codes, strengthening risk adjustment scores and closing quality gaps.

One patient. One relationship. One team. Three active programs generating revenue, closing quality gaps, and preventing avoidable utilization simultaneously.

PROVEN AT SCALE

Results across every care management program we deliver

A large healthcare organization replaced internal triage with Guideway Care. The result: consistent quality, predictable costs, and nearly $1M in projected savings.

$192,060

Projected annual CCM reimbursement (250 patients)
99.4%

Quality KPI pass rate
35%

Fewer readmissions
31%

Higher patient satisfaction
24/7

RN coverage, zero gaps

Network Steerage for Payers

Written on March 25, 2026.

Network Steerage for Payers & Health Plans

Your Members Need Care.
They’re Getting It Out of Network.

Every out-of-network visit is excess cost and a member one step closer to leaving your plan entirely. We guide members to in-network providers at the moment of need — before the decision is made.

The Challenge

The Network Steerage Problem

Members aren’t intentionally going out of network. They’re going wherever is easiest — because nobody guided them to the right in-network option at the right time.

Members leave your network because nobody guided them to an in-network option

When a member needs care and can’t quickly identify an in-network provider, they default to the most convenient option — which is often out of network. That’s a permanent reduction in the value of that attributed life.

Out-of-network utilization inflates your total cost of care

Every out-of-network visit, procedure, or specialist encounter costs more than the in-network equivalent. For plans managing total cost of care, network leakage is a direct hit to your bottom line.

Provider directories don’t solve the navigation problem

A searchable directory assumes members will self-serve their way to the right provider. In practice, members are confused by plan terms, overwhelmed by options, and uncertain which provider is appropriate for their need.

Root Cause

As Healthcare Experts, We See the Deeper Problem

Network steerage isn’t a directory problem. It’s a navigation problem that requires human guidance at the moment of decision — before the member has already chosen an out-of-network path.

Members don’t understand their network well enough to navigate it

DECISION COMPLEXITY

Primary care vs. specialist, in-network vs. out-of-network, referral required vs. self-referral — the complexity of modern health plan design creates decision paralysis that defaults to the path of least resistance.

See the disposition breakdown →
Network steerage must happen at the moment of need, not after

TIMING

A member experiencing symptoms calls their plan or searches online. If an in-network option isn’t presented within that decision window, the member has already made their choice. Steerage after the fact is too late.

See the disposition breakdown →
Members with existing out-of-network relationships are hard to redirect

RELATIONSHIP

A member who has been seeing an out-of-network specialist for years won’t switch because of a directory listing. Steerage requires a conversation about why the transition matters and how to make it seamless.
The highest-cost services have the highest out-of-network rates

HIGH-COST SERVICES

Surgical procedures, imaging, and specialist encounters — the services that cost the most are where network leakage is most expensive. These are also the services where members feel most uncertain about where to go.

Our Approach

Activation-Driven Network Steerage

We guide members to in-network providers through live agent engagement — matching them to the right provider, scheduling the appointment, and following up to confirm completion.

Real-time steerage during symptom and scheduling calls

When members call about symptoms or need help scheduling, our agents guide them to in-network providers in real time — not after the visit has already happened.
Activation-driven provider matching

We don’t just give members a list. We match them to specific in-network providers based on location, availability, specialty, and the member’s specific needs — then schedule the appointment during the call.
High-cost service steerage

For surgical, imaging, and specialist referrals, we proactively guide members to high-value in-network providers, reducing out-of-network utilization where it matters most.
Transition support for members with OON relationships

For members who have been seeing out-of-network providers, we facilitate the transition with empathy, education, and practical scheduling support.
Closed-loop confirmation

We follow up to confirm the member completed the in-network visit. Steerage without follow-through is just a suggestion.

PROVEN AT SCALE

Keeping Members In Network, In Care

When members are guided to in-network providers at the moment of need, utilization costs drop and member satisfaction rises.

30%

Readmission reduction

5×

Activation rate increase

99.4%

QA pass rate

Behavioral science techniques

Ready to keep your members in network?

Schedule a consultation and see how activation-driven steerage can reduce out-of-network utilization and total cost of care.

Schedule a Consultation

RAF Score Capture for Payers

Written on March 25, 2026.

RAF Score Capture for Payers & Health Plans

Your Members Have Chronic Conditions.
Your RAF Scores Don’t Reflect It.

Every uncaptured HCC code is lost revenue for the full plan year. We activate members to complete the visits where RAF capture happens — on time, every year.

The Challenge

The RAF Capture Problem

RAF scores drive your revenue. But the members whose conditions need to be captured are the hardest to engage — and automated reminders aren’t moving them.

Inaccurate RAF scores cost you revenue on every attributed member

When HCC codes aren’t captured during annual wellness visits or chronic care encounters, your risk adjustment revenue drops. Every uncaptured condition is money you’ve earned but never collected.

Members skip the visits where RAF capture happens

Annual wellness visits, chronic care management appointments, and comprehensive assessments are the encounters where HCC codes get captured. When members don’t show up, the codes don’t get documented.

Automated reminders about ‘annual check-ups’ don’t create urgency. Members see them as optional. The visits that matter most for RAF capture are the ones members are most likely to skip.

Without clear, immediate guidance and friction-free next steps, anxious patients default to the emergency department.

Root Cause

As Healthcare Experts, We See the Deeper Problem

RAF capture isn’t a coding problem. It’s a visit completion problem. And visit completion for complex chronic members requires barrier resolution and activation, not reminders.

Every uncaptured HCC code is lost revenue for the full plan year

REVENUE AT RISK

RAF scores determine capitation rates. When chronic conditions go undocumented because the member didn’t complete the encounter, your revenue for that member is lower than it should be — for the entire year.

See the disposition breakdown →
The visits that drive RAF capture have the highest no-show rates

VISIT COMPLETION

Members with the most chronic conditions — and therefore the most HCC codes to capture — are often the hardest to engage. They face the highest barrier burden and need the most activation to complete visits.

Understand activation symptoms →
Network providers aren’t always capturing codes at the encounter

PROVIDER ALIGNMENT

Even when members complete visits, providers may not document all relevant HCC codes. The capture problem has two stages: getting the member to the visit, and ensuring the visit captures everything.

The escalator model →
RAF capture is a calendar-year game — and the window closes fast

TIMING

HCC codes must be captured within the measurement year. Members who haven’t completed their annual visit by Q3 represent rapidly diminishing time to capture. Activation urgency increases every month.

Quantify the leakage →

Our Approach

Activation-Driven RAF Capture

We activate members to complete the visits that capture HCC codes — prioritizing by risk, resolving barriers, and confirming visit completion through closed-loop follow-up.

Activation-driven outreach for RAF-critical visits

Our agents don’t just remind members about annual visits. They use behavioral science to create urgency, resolve barriers, and schedule the appointment during the call.
Risk-stratified prioritization

Members with the highest suspected HCC burden are prioritized first. Our platform identifies which members represent the largest RAF capture opportunity.
Barrier resolution for high-complexity members

Members with multiple chronic conditions face more barriers. Transportation, specialist coordination, medication concerns — we resolve them before they become no-shows.
Closed-loop visit confirmation

We don’t just schedule the visit. We follow up to confirm the member attended, the encounter was documented, and the relevant codes were captured.
Integration with your population health data

We work from your member data to identify gaps, track completions, and report on RAF capture progress in real time.

PROVEN AT SCALE

Maximizing RAF Revenue Through Member Activation

When members complete RAF-critical visits, your risk adjustment revenue reflects the true acuity of your population.

5×

Activation rate increase

40%

Visit activation rate

99.4%

QA pass rate

24/7

Coverage available

Ready to capture the RAF revenue you’re leaving on the table?

Schedule a consultation and see how activation-driven outreach can improve your RAF accuracy and risk adjustment revenue.

Schedule a Consultation

Care Gap Closure for Payers

Written on March 25, 2026.

Care Gap Closure for Payers & Health Plans

Your Members Know About the Gap.
They Just Don’t Close It.

Care gap reminders reach members. Activation-trained agents move them to action. We close the gap between outreach and completion with behavioral science and barrier resolution.

The Challenge

The Care Gap Closure Problem

You’ve invested in outreach infrastructure. The gaps remain open. The issue isn’t awareness — it’s activation.

You send millions of reminders. Members still don’t close their gaps.

Letters, portal notifications, automated calls — the volume of outreach is high. The conversion to completed action is low. Because most outreach measures whether the message was sent, not whether the member did anything about it.

Half of non-compliance is driven by barriers your outreach never asks about

Transportation, cost confusion, competing priorities, fear of results — 50% of non-adherence stems from SDOH factors. A reminder can’t resolve what it doesn’t address.

Every unclosed gap is a missed quality measure and potential penalty

HEDIS scores, Star Ratings, and quality bonuses all depend on gap closure rates. The financial impact of low closure rates compounds across your attributed population.

Root Cause

As Healthcare Experts, We See the Deeper Problem

Awareness doesn’t drive action. Activation does. The gap between knowing about a care gap and actually closing it requires human engagement, barrier resolution, and behavioral science.

Your outreach program measures sends, not completions

OUTREACH MODEL

The gap between ‘member was contacted’ and ‘member completed the action’ is where your quality scores are made or lost. Most programs optimize for the former and hope for the latter.
Automated outreach can’t resolve the barriers that prevent action

BARRIER BLINDNESS

A member who doesn’t understand what a ‘care gap’ means, can’t get transportation to the appointment, or is managing three competing priorities won’t be moved by a reminder letter. They need a conversation.
One-size-fits-all outreach produces one-size-fits-none results

SEGMENTATION

Members with different risk profiles, SDOH burdens, and engagement levels need different approaches. A healthy 35-year-old missing a screening needs a different conversation than a complex chronic patient missing three gaps.
Outreach that doesn’t match the member’s readiness window gets ignored

TIMING

Members have moments of receptivity — after a health scare, during open enrollment, at a life transition. Generic outreach on a fixed schedule misses these windows entirely.

Our Approach

Activation-Driven Care Gap Closure

We move members from awareness to action through live agent engagement, barrier resolution, and real-time scheduling — reporting on completions, not contacts.

Activation-trained agents, not automated messages

Our agents are trained in 9 behavioral science techniques to move members from awareness to completed action. Every call is designed to close the gap, not just communicate about it.
SDOH-aware barrier resolution

Transportation, cost, language, and psychosocial barriers are identified and resolved during the call. We don’t just tell members to schedule — we help them get there.
Risk-stratified member segmentation

Our platform segments members by clinical risk, SDOH profile, payer type, and engagement history. Each member gets the right approach at the right time.
Real-time scheduling and coordination

We don’t just encourage members to schedule. We schedule the appointment during the call, confirm transportation, and follow up to ensure completion.
Closed-loop reporting on completions, not contacts

We report on gaps closed, not calls made. Your quality team sees the metrics that matter for HEDIS, Star Ratings, and quality bonuses.

PROVEN AT SCALE

5× Activation Rate Increase in 90 Days

A large clinically integrated network achieved 40% activation rate for ACO provider appointments through activation-trained outreach.

5×

Activation rate increase

40%

Gap closure activation rate

99.4%

QA pass rate

Behavioral science techniques

Ready to close gaps instead of just reminding about them?

Schedule a consultation and see how our verification specialists can protect your revenue, free your staff, and keep patients moving toward care.

Schedule a Consultation

Preventable Denials and Revenue Leakage in Insurance Verification

Written on March 25, 2026.

INSURANCE VERIFICATION

Revenue Leakage from Preventable Insurance Verification Denials

You built a denial management team to recover lost revenue. But the question nobody is asking: why are these denials happening in the first place? Most eligibility and authorization denials trace back to a single failure point. Verification.

WHAT YOU ALREADY KNOW

Your Revenue Cycle Team Knows the Drill. Appeal. Rework. Repeat.

Your revenue cycle team knows the drill. Claims come back denied for eligibility, authorization, or referral issues. They file appeals. Some succeed. Many don’t. The ones that do still cost more in staff time than the original verification would have.

This cycle is so normalized that most organizations treat it as a cost of doing business. They staff for it. They budget for it. They build workflows around managing denials rather than preventing them.

But every one of those denials started at verification. A coverage check that stopped at “active” without confirming plan-specific requirements. An authorization that was needed but never requested. A referral requirement that wasn’t flagged before the appointment. Surgical benefits that were assumed based on a similar plan from a different payer.

The denial didn’t happen at billing. It happened weeks earlier when a rushed or incomplete verification let a gap through that nobody caught until the claim was rejected.

WHAT MOST LEADERS MISS

The True Cost Extends Far Beyond the Denied Amount

Revenue leakage from verification failures is worse than most organizations measure, because the true cost extends far beyond the denied amount.

The visible loss is the denied claim. The invisible loss is the infrastructure built to recover it. Most practices and health systems employ dedicated staff for denial management, appeals, and follow-up. That team exists largely because of upstream failures in verification and authorization. If the verification was thorough, many of those positions wouldn’t need to exist, or could be redirected to higher-value revenue cycle work like contract analysis or underpayment recovery.

Write-offs accumulate below the attention threshold. Small denials under a few hundred dollars rarely get appealed. The cost of the appeal exceeds the recovery. So they get written off. One at a time, they’re invisible. Over a fiscal year, they represent a material gap between what you earned and what you collected. These small write-offs are almost entirely the product of verification shortcuts.

Denial patterns attract payer scrutiny. Payers track your denial rates. A consistently high rate on eligibility and authorization denials signals to the payer that your verification processes are weak. That signal invites additional review on future claims, including claims that were submitted correctly. Your verification failures are now affecting the speed and reliability of your entire claims pipeline.

The compounding effect is real. Denied claim leads to appeal. Appeal requires staff time. Staff time diverted from other revenue cycle work. Other work falls behind. More claims age. Aged claims are harder to collect. Collection rates drop. Margin shrinks. The verification gap at the front end created a cascade that hits the bottom line from multiple directions.

Organizations that track their “cost to collect” often find that preventable denials are the largest single driver of that cost. The fix isn’t better denial management. It’s better verification.

HOW WE SOLVE IT

Close the Verification Gap Before It Becomes a Denial

We close the verification gap before it becomes a denial. Our Medical Contact Center specialists complete pre-authorization, pre-certification, and pre-determination for every patient through structured workflows. They verify insurance type, confirm surgical benefits, and document PCP referral requirements, all within your EHR through controlled user access.
Gaps don’t slip through

Because every verification follows the same process with quality assurance oversight, gaps don’t slip through. Authorization requirements get flagged before scheduling, not after the claim is denied.
Benefits confirmed in writing, not assumed

Benefits get confirmed in writing, not assumed from a similar plan. The documentation is complete, specific, and audit-ready.
A cleaner revenue cycle from intake to collection

Fewer denials originating from verification failures, less rework for your billing team, and a cleaner revenue cycle from intake to collection.

Schedule a Consultation See our full Insurance Verification approach

IF YOU’RE SEEING THIS, YOU’RE LIKELY FACING THESE TOO

Related Challenges

Incomplete verifications are the root cause of most eligibility denials

The denied claim is the symptom. The incomplete verification is the cause. Most organizations treat the symptom.

How verification gaps cause denials
Inconsistent verification processes create audit exposure

When verification quality varies by staff member, your audit outcomes vary too. That inconsistency compounds the revenue leakage.

The compliance cost of ad hoc verification
Staff burden from manual verification leads to the shortcuts that cause denials

Overloaded staff cut corners. Those corners are where denials are born.

The real cost of manual verification

Back to Insurance Verification Solutions

PROVEN AT SCALE

From revenue leakage to revenue protection

200+

Partner clients

22+

Years healthcare-only

HIPAA

Compliant · SOC 2 Certified

Protect your revenue at the source.

Schedule a consultation and see how thorough, consistent verification eliminates the denials your billing team is spending months recovering.

Schedule a Consultation

Leading and lagging KPIs in Healthcare

Written on August 28, 2025. Posted in Blog.

In the era of value-based care, measuring performance in healthcare is more critical than ever. Hospitals, clinics, and health systems rely on key performance indicators (KPIs) to evaluate outcomes, track progress, and guide decisions. Among these, the distinction between leading and lagging indicators provides a framework for understanding not just what has already happened but also what is likely to occur. Healthcare organizations often ask how to best apply leading vs lagging KPIs to improve both clinical and operational outcomes. By using both perspectives together, providers can monitor past performance while predicting and influencing future results. This balance creates a more complete view of healthcare delivery and enables better strategic planning.

What Are Leading Indicators?

Leading indicators are predictive measurements that anticipate future performance. In healthcare, these often involve proactive actions or early signals that point toward likely outcomes. Examples include:

The number of patients enrolled in preventive screenings.
Staff training completion rates for new protocols.
Patient engagement levels in chronic disease management programs.
Appointment follow-up confirmations after hospital discharge.

Because they are forward-looking, leading indicators help organizations make adjustments before problems escalate. For instance, low preventive screening participation could signal potential increases in chronic disease cases, prompting intervention. Leading and lagging indicators work best when aligned. While leading indicators focus on inputs and processes, lagging indicators confirm whether those efforts achieved the desired results.

What Are Lagging Indicators?

Lagging indicators measure outcomes that have already occurred. These are typically easier to quantify and are often tied to industry benchmarks. Examples include:

Hospital readmission rates within 30 days.
Average patient satisfaction scores.
Mortality or complication rates following surgery.
Revenue and cost per patient episode.

Lagging indicators confirm whether strategies were successful, but don’t provide insight into future risks. For example, high readmission rates show that patient follow-up or discharge processes were insufficient, but the data come after the negative outcome. Balancing lagging and leading indicators is essential for long-term improvement. Lagging metrics confirm results, while leading metrics point to the actions required to sustain or improve them.

Why Leading vs Lagging KPIs Matter in Healthcare

The debate over leading vs lagging KPIs often comes down to timing and control. Lagging indicators tell you how you did in the past, while leading indicators provide insight into what you can influence moving forward. In healthcare, this distinction is critical because patient outcomes, safety, and organizational sustainability depend on early action. Relying only on lagging metrics is like driving by looking in the rearview mirror. Without leading metrics, providers lack visibility into risks until it is too late. On the other hand, leading indicators without lagging validation can lead to misguided strategies. An organization may invest heavily in preventive programs but fail to confirm whether those efforts reduce hospital admissions. That’s why both metrics are required for a complete performance management strategy.

KPI in Healthcare: Building a Balanced Framework

Every KPI in healthcare should align with organizational goals and industry standards. But achieving balance means using a combination of leading and lagging indicators. Key categories for healthcare KPIs include:

Clinical outcomes: mortality rates, infection rates, and readmissions.
Patient experience: satisfaction surveys, access to care, and wait times.
Operational efficiency: staffing ratios, resource utilization, and appointment scheduling.
Financial performance: revenue cycle metrics, cost per patient, and payer mix.
Population health: preventive screening rates and chronic disease management.

By designing KPIs that incorporate both predictive and outcome-based measures, organizations create systems that track not just performance but progress toward sustainable, value-based care. This balanced approach demonstrates how leading vs lagging KPIs can work together to provide both foresight and validation in healthcare management.

Leading and Lagging Indicators Examples in Healthcare

It helps to look at leading and lagging indicators examples side by side: Leading Indicators

Percentage of patients enrolled in smoking cessation programs.
Number of follow-up calls made within 48 hours of discharge.
Compliance rate for staff hand hygiene protocols.
Uptake of new clinical decision-support tools.

Lagging Indicators

Hospital-acquired infection rates.
Readmission rates for chronic obstructive pulmonary disease (COPD).
Patient-reported outcomes after surgery.
Average length of stay in acute care.

This contrast highlights how leading indicators focus on actions, while lagging indicators measure results. For healthcare executives, using both sets of metrics together ensures a complete understanding of system performance.

Balancing Leading and Lagging Indicators

The challenge for many organizations lies in striking the right balance. Too much reliance on lagging metrics leads to reactive decision-making. Overemphasis on leading indicators without validation risks misallocation of resources. Best practices include:

Pair every lagging indicator with at least one related leading indicator.
Use real-time dashboards to monitor predictive metrics continuously.
Set thresholds for early intervention when leading indicators suggest risk.
Compare historical lagging data with current leading trends to forecast future outcomes.

For example, high patient satisfaction (lagging) should be paired with measures like average response time to patient inquiries (leading). This ensures organizations are not just recording outcomes but actively influencing them.

Strategies for Implementing KPIs in Healthcare

Implementing an effective KPI framework requires planning, collaboration, and technology. Recommended strategies include:

Engage stakeholders: Clinicians, administrators, and patients should all contribute to defining KPIs.
Leverage technology: Analytics platforms provide real-time insights into both leading and lagging indicators.
Train staff: Employees must understand why metrics matter and how their actions influence results.
Review regularly: Frequent reviews allow organizations to adjust strategies before problems escalate.
Tie to incentives: Linking KPIs to performance-based rewards ensures accountability.

By following these strategies, healthcare organizations can move from reactive management to proactive improvement.

Leading vs Lagging Indicators: Which Should You Prioritize?

The debate over leading indicators vs lagging indicators is less about choosing one and more about how to integrate both. Leading indicators guide strategy by predicting outcomes, while lagging indicators validate whether those strategies worked. Healthcare organizations should prioritize a dual approach:

Use leading indicators to anticipate risks and opportunities.
Use lagging indicators to confirm results and measure long-term trends.

When integrated effectively, both perspectives create a dynamic feedback loop that strengthens decision-making and aligns with value-based care objectives.

The Future of KPIs in Healthcare

The future of KPIs in healthcare will be driven by real-time analytics, predictive modeling, and artificial intelligence. These tools allow providers to identify risks earlier, personalize care pathways, and forecast outcomes more accurately. For example, predictive algorithms can analyze leading indicators such as patient lifestyle data, appointment adherence, and biometric monitoring to predict the likelihood of hospital readmission. When combined with lagging indicators like historical readmission rates, providers gain a powerful tool for improving patient care and reducing costs. As digital health expands, the role of leading and lagging indicators will continue to grow, offering new ways to connect data with patient-centered outcomes.

Balancing Metrics for Better Outcomes

Leading and lagging indicators provide healthcare organizations with complementary insights. Leading indicators anticipate future performance, while lagging indicators measure past outcomes. Together, they form the foundation of effective KPIs in healthcare, ensuring providers can both predict and validate success. For organizations seeking to optimize KPI frameworks, Guideway Care offers solutions that align clinical, operational, and financial performance with measurable outcomes. By combining deep healthcare expertise with advanced analytics, they help providers strike the right balance between leading and lagging KPIs.

The Impact of Managed Care on Value-Based Healthcare

Written on July 9, 2024. Posted in Blog.

A managed care organization (MCO) can add to the success of value-based care. Healthcare facilities are adopting MCOs to improve their patient outcomes while controlling the costs. What managed care organizations do in value-based care is use preventive health, population health management, and care coordination to manage patient care. They also coordinate between the various payers—including Medicare, Medicaid, and private employers—to provide comprehensive healthcare services. By focusing on patients with chronic or complicated conditions, MCOs help to reduce unnecessary medical expenses and improve overall health outcomes.

Value-Based Care Models

In value-based care models, healthcare providers are incentivized by the payers to achieve specific health outcomes. The Bundled Payments for Care Improvement (BPCI) Advanced is a program that does just that. Payers can manage how payments are made and decide who is in their network. That helps to ensure cost-effective and high-quality care. This model highly encourages providers to focus on their patient outcomes rather than the number of services (pap smears, vaccinations, CT scans, etc.) that they provide in their practice each week.

Managed Care Plans—HMOs and More

Managed care plans come in different forms. These include HMO, PPO, Point of Service (POS), and Exclusive Provider Organization (EPO) plans. Each plan offers varying levels of flexibility and cost management. They are best tailored to meet the needs of different patient populations.

Not Just Focused on Payment

The role of managed care in value-based care does more than focus on payments. MCOs invest in technologies and data analytics to track patient outcomes and identify areas that need improvement in healthcare facilities. This proactive approach helps in managing the health of various populations. Consequently, patients receive the right care at the right time. This can be quite beneficial to struggling populations that have fewer doctors or facilities.

Meeting the Metrics

How does it work? The BPCI Advanced program rewards providers for meeting specific patient outcomes. This creates a financial incentive for providers to deliver high-quality care while keeping the expenses reasonable. Payers, including both public and private, collaborate with managed care organizations to create value-based care models. They ensure that providers have the resources and incentives necessary to then achieve better health outcomes for their patients.

Bringing the Payer, Provider, and Patients Together

Ultimately, managed care organizations are essential to transition from the past flawed systems to value-based care. They bring together payers, providers, and patients to create a healthcare system that prioritizes quality and efficiency. This not only improves patient outcomes but reduces healthcare costs at the same time.

For more information on managed care in value-based care models, consult our experts at Guideway Care. Let us work with you to implement proven systems like BPCI Advanced and enhance the overall patient experience.

In conclusion, managed care has become a critical driver in advancing value-based healthcare, offering improved patient outcomes and cost efficiencies through coordinated efforts. By leveraging innovative solutions and fostering collaboration among hospitals and health systems, oncology practices, risk-bearing entities, payers, bundle participants, and behavioral health providers, the healthcare industry can continue to thrive in delivering comprehensive, patient-centric care. As the landscape evolves, embracing these changes ensures a sustainable, value-driven approach to meet the growing demands of modern healthcare systems.

Essential Strategies to Enhance and Implement Value-Based Care

Written on July 2, 2024. Posted in Blog.

Value-based care (VBC) is a revolutionary provider payment model that rewards high-quality healthcare rather than the quantity of services provided. VBC and other advanced payment models, like Bundled Payments for Care Improvement (BPCI), aim to improve patient outcomes while reducing healthcare costs. Here are key strategies to implement value-based care effectively in your practice.

Identifying High-Risk Patients

One of the main strategies to implement value-based care is identifying patients with the highest risk. These patients usually have chronic conditions or multiple health issues that require frequent medical attention. Using data analytics and risk classification tools, healthcare providers can pinpoint these individuals and prioritize their care. Early identification allows for proactive management of their conditions, reducing hospital admissions and improving overall health outcomes.

Addressing Patients With Immediate Care Needs

After identifying high-risk patients, addressing those needing immediate care is essential. This involves creating personalized care plans tailored to their specific health needs. Healthcare professionals can prevent minor health issues from worsening by focusing on timely interventions and continuous monitoring. This helps to improve patient outcomes and reduce healthcare costs. Coordinated care teams, including primary care physicians, specialists, and case managers, are vital in delivering comprehensive and efficient care to these patients.

Promoting Annual Wellness Visits

Another value-based healthcare strategy is encouraging patients to attend annual wellness visits. These visits allow healthcare providers to conduct preventive screenings, update vaccinations, and review patients’ overall health status. Regular wellness visits help in the early detection of potential health issues, allowing for timely interventions. They also foster a strong patient-provider relationship, enhancing patient engagement and adherence to care plans.

Maintaining Open Communication With Provider-Relation Representatives

Value-based care strategies also entail effective communication with provider-relation representatives. This is crucial as representatives are liaisons between healthcare providers and payers, navigating the complexities of VBC contracts and performance metrics. In addition, keeping open lines of communication ensures that providers are well-informed about the requirements and expectations of VBC programs. This ultimately improves the quality of care patients receive.

Implementing and improving value-based care requires a multifaceted approach that prioritizes patient-centered strategies. By implementing value-based care strategies, healthcare providers can achieve the primary goal of enhancing patient outcomes while reducing the cost of care. Contact Guideway Care and schedule a consultation with our experts to implement these strategies successfully and improve the quality of healthcare and the overall sustainability of the healthcare system.

Understanding the Key Differences Between Fee-For-Service and Value-Based Care Models

Written on September 15, 2023. Posted in Blog.

In the healthcare industry, two main payment models have emerged: fee-for-service vs value-based care. As healthcare providers and patients navigate these two approaches, it’s important to understand their distinctions and how they impact the quality and cost of care.

Fee-For-Service: Paying for Quantity

Under the traditional fee-for-servicemodel, healthcare providers are reimbursed for each individual service they perform. The more procedures, tests, and treatments a provider delivers, the higher their payment. While this fee-for-service structure offers transparency in billing, it has some notable drawbacks:

Incentivizes quantity over quality
Can lead to unnecessary tests and procedures
May result in higher costs for patients
Lacks focus on patient outcomes and care coordination

This fee-for-service approach, while straightforward, may not always align with delivering the most effective and efficient care for patients.

Value-Based Care: Prioritizing Quality Outcomes

In contrast, the value-based care modelprioritizes the quality of care over the quantity of services provided. Under this model, healthcare providers are rewarded for achieving positive patient outcomes and delivering high-quality, coordinated care. The value-based healthcare approach offers several advantages when compared to fee-for-service:

Encourages providers to focus on prevention and patient well-being
Promotes collaboration among healthcare teams
Can lower healthcare costs by reducing unnecessary services
Emphasizes data-driven decision-making to improve care quality

By shifting the focus from volume to value, this model aims to deliver better care experiences and outcomes for patients.

Navigating the Transition

As healthcare systems recognize the benefits of value-based oncology care and care across all medical specialties, many are working to transition away from fee-for-service to value-based care models. However, this shift requires significant changes in how providers operate and get paid. To successfully navigate this transition, healthcare organizations must:

Invest in robust health IT systems to track and analyze patient data
Foster a culture of continuous quality improvement
Educate staff on new payment models and performance metrics
Collaborate with payers to develop value-based contracts
Engage patients in their care and gather their feedback

While change can be challenging, embracing value-based care over fee-for-service models offers an opportunity to transform healthcare delivery for the better.

Partner With Guideway Care for Value-Based Care Success

Guideway Care understands the complexities of transitioning to value-based care. Our healthcare navigation solutions help oncology practices succeed in this new landscape by providing personalized patient support, care coordination, and data analytics. With our expertise and technology, we can help your practice deliver high-quality, patient-centered care while thriving under value-based payment models. Contact us today to learn more about our services and how we can support your value-based care success.

Risk Bearing Entities

Written on August 2, 2022.

Who We Serve

Transforming Risk Management
for Utilization, Cost Efficiency
and Member Satisfaction

Our evidence-based patient activation solution helps risk-bearing organizations—payors, ACOs, and bundled payment providers—lower costs, improve adherence, and boost member satisfaction.

Guideway Care’s tailored approach empowers risk-bearing organizations to mitigate financial risk and drive quality outcomes through proactive, evidence-based patient activation. By leveraging a combination of advanced technology, data-driven insights, and our specially trained Patient Activation Agents (PAA) and Guides (PAG), we streamline care processes, improve member adherence, and ensure that every patient member takes the necessary steps toward optimal health.

Our Key Outcomes

Lower Costs

Our solution systematically reduces avoidable healthcare utilization by addressing barriers to care early. Risk-bearing organizations have experienced cost reductions of up to 25–30% in avoidable claims and acute care events, leading to significant overall savings. For Medicare oncology populations, we’ve lowered ER visits by 29%, decreased hospitalizations by 55% and decreased ICU admissions by 60%.
Promote Adherence

Consistent and personalized patient activation helps members follow their care plans—from maintaining medication routines to keeping scheduled follow-up appointments. Data from our programs indicate improvements in adherence rates by as much as 35–40%, ensuring that patient members receive the full benefit of recommended therapies and reducing the incidence of complications.
Enhance Member Satisfaction

Our evidence-based patient activation model streamlines the care experience by proactively addressing non-clinical barriers, ensuring members receive personalized, timely support. As a result, risk-bearing organizations have reported improvements in member satisfaction scores of 10–15%, reflecting smoother care processes, increased trust, and a more positive overall health management experience.

Close the Gap with Evidence-Based Patient Activation

It’s time to close the engagement gap in your organization.

Don’t settle for costly programs that maintain the status quo. Download our Short Guide to Evidence-Based Patient Activation to learn how Guideway Care can drive better outcomes and financial performance for you. See the data, case studies, and model behind this proven solution – and discover how to finally achieve the patient engagement breakthrough your team has been looking for. Get the guide now and start your journey to real patient activation and real results.

Evidence-Based Patient Activation Guide

Schedule a Strategic Analysis to Explore How Our EBPA Can Help You

Schedule Analysis

Low-Value Care | Patient in a CT Scanner

Low-Value Care: What It Is, and 3 Strategies to Reduce It

Written on February 4, 2020. Posted in Blog.

The phrase “low-value care” is frequently tossed around in discussions of healthcare spending, and there are whole initiatives dedicated to reducing the use of low-value services in clinical settings. However, a comprehensive understanding of low-value care and its impact on health outcomes is essential to identifying and ultimately reducing its occurrence in healthcare.

What is Low-Value Care?

Low-value care is defined as services that are medically unnecessary and provide no health benefits to patients. In some cases, low-value care can even be harmful to the patient and/or lead to further unnecessary testing or treatment. Examples of low-value care include:

Running lab tests for low-risk patients before a low-risk procedure.
Ordering head CT scans for simple dizziness or an EEG for a headache.
Using costly branded drugs instead of identical generics.
Performing surgery when physical therapy would be equally effective.
Inappropriately prescribing antibiotics.

The use of low-value services by providers is often driven by a variety of factors, including established clinical practices and workflows, patient expectations, information disparities, fear of malpractice, and fee-for-service payment systems. “The current economic incentives in healthcare typically reward the provision of more services, regardless of their value to the patient,” Beth Bortz, president and CEO of the Virginia Center for Health Innovation, explained to Managed Healthcare Executive. Not only can these services be harmful to patients, but low-value care is also a significant source of waste in the U.S. healthcare system—research in JAMA estimates that $12.8 billion to $28.6 billion could be saved annually if measures were taken to reduce overtreatment and low-value care.

3 Strategies for Reducing Low-Value Services

Given the high cost and potential harm of low-value care, many healthcare organizations are attempting to reduce their use of unnecessary services and overtreatment using the following strategies.

Awareness Campaigns for Both Providers and Patients As mentioned above, there are a number of initiatives dedicated to reducing the use of low-value services in clinical settings, including Choosing Wisely by the American Board of Internal Medicine Foundation. This popular initiative aims to encourage patient-provider communication about unnecessary medical procedures, and the organization provides a wide range of educational resources for both parties that can help reduce the prevalence of low-value services.Using these resources, healthcare organizations can promote awareness of low-value care among both providers and patients. Leadership may want to talk to staff about the Choosing Wisely “Top 12”—recommendations that drive the largest decrease in unnecessary tests and procedures. It can be beneficial to give patients access to educational resources about low-value services and important questions to ask their physicians.
Provide Clinical Decision Support Tools Physicians will not always have the opportunity to consult resources when making choices about patient care, which is why clinical decision support tools are extremely valuable. These tools provide physicians with timely information and care recommendations, typically at the point of care, allowing them to make more informed decisions and avoid unnecessary, low-value services.
Involve Patients in Decision-Making One of the major challenges to reducing low-value care is overcoming patient expectations. According to Altarum’s Healthcare Value Hub, many patients have a problem accepting no treatment as the best course of action, leading physicians to use low-value services to satisfy them.To overcome this obstacle, healthcare organizations should not only educate patients about low-value care but also involve them in clinical decision-making when practical. When doctors and patients work together to make treatment decisions, select tests, and create care plans, it serves to improve communication between the two parties and can actually reduce the use of low-value services. According the Healthcare Value Hub, as many as 20 percent of patients who participate in shared decision-making opt for less invasive surgical options and more conservative treatment plans than patients who are not involved in the process.

What is BPCI (Bundled Payments for Care Improvement)?

Written on October 30, 2019. Posted in Blog.

Bundled Payments for Care Improvement (BPCI) was an initiative created by the Center for Medicare and Medicaid Innovation (CMMI) to test the efficacy of several different episode-based payment models in producing higher quality, more coordinated health care at a lower cost to Medicare. BPCI was launched in 2013 concluded in 2018. The BPCI Advanced Model is a new iteration of the program and a continuation of efforts to implement episode-based payment models, also referred to as bundled payments.

Bundled Payments and BPCI

In traditional fee-for-service (FFS) payment models, providers are paid for each individual service they furnish to patients for a single illness or course of treatment. Bundled payments provide a single, comprehensive payment that covers all services provided during a patient’s episode of care (services provided to a beneficiary with a medical condition within a specific time frame and across the continuum of care). Medicare has been working towards reducing healthcare costs through episode-based payments for more than three decades, beginning with the introduction of the inpatient prospective payment system (IPPS) in 1983. BPCI was the most ambitious and wide-ranging bundled payment initiative CMS had ever attempted, and included hospitals, physician groups, post-acute facilities, and more. BPCI participants could choose from one of four models, and three of the four models gave participants the ability to further specify which of 48 different clinical episodes they would include. Each of the four BPCI models had important differences in which portions of the continuum of care were included, as well as in how payments were made and discounts calculated. Specifically, each model varied in:

Eligible participants
Clinical conditions included
Included services (various combinations of inpatient, post-acute, and readmissions)
Expected discount
The method for provider payments
Quality measures used

Was the Initiative Effective?

The overarching goal of bundled payment models, including BPCI, is to reduce the cost of care while preserving or improving outcomes. There is clear evidence that BPCI participants that included surgical procedures in their bundle have achieved both cost and quality improvements, but more progress needs to be made in bundles focused on chronic conditions. Timing may be an issue, as hospitalizations correlate well as the beginning of a surgery-involved episode, but are unlikely to align with the onset of a chronic medical condition. In order to thrive under bundles for chronic conditions, hospitals will have to take a more proactive approach and tackle non-clinical issues that feed into chronic conditions, including social determinants, though most currently lack the mechanisms to do so.

BPCI Advanced

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is the new iteration of BPCI. The new model aims to build on the successes of BPCI, while making modifications to correct deficiencies in the old program. Some key differences include:

A wider view of the episode of care – the duration of all clinical episodes now includes the anchor stay + 90 days, while the original BPCI program allowed participants to choose from 30- 60- or 90-day bundles.
There is a higher element of risk, with the following elements all playing a role:
- Fewer exclusions are allowed – all Part A services resulting from the Anchor Stay/Procedure are be included, as well as post-acute services, including home and hospice care. Participants must expand their cost and quality efforts to include services previously excluded from the bundle.
- Up to 10% of payments are at risk for quality performance – this differs from the original program, which had no quality component.
- Downside financial risk will take effect immediately – the phase-in period utilized in the original program is not part of BPCI Advanced.
- Outliers are more narrowly defined as the 1st and 99th percentile – the original program allowed three tracks (1st and 999th, 5th and 95th, or 5th and 75th) for determining which patients episodes would be capped before inclusion in cost calculations, based on their status as an outlier.
Changes to align with other quality programs, prevent overlap, and incentivize physician group practices (PGPs):
- BPCI Advanced will qualify as an Advanced Alternative Payment Model (Advanced APM) through the Medicare Access and CHIP Reauthorization Act (MACRA) – this could incentivize physician group practices and hospital-employed physicians to participate in order to avoid payment adjustments under the Merit-based Incentive Payment System (MIPS).
- Next Generation or Track 3 MSSP ACOs are excluded – participants in these and other APMs will need to be aware of the rules regarding how and when various payment models may be implemented.
- Hospitals could lose episodes to PGPs – in the original BPCI program PGPs were in the minority, and were at a disadvantage if they joined in Phase II as opposed to Phase 1. Under BPCI Advanced, PGPs will always take precedence.

The opportunities presented by BPCI Advanced will allow participants to progress in terms of value-based care, but will also present increased risk and less flexibility than the original program. It remains to be seen whether the updates to the BPCI model will produce additional benefits, but it’s clear that CMS will continue to drive towards value-based care with episode-based reimbursement models.

Additional resources:

Non-clinical care guidance reduces unnecessary utilization while improving patient satisfaction. Request Contact for more information about how Guideway Care can help your organization succeed in bundles today.

Why a Third of Orthopedic Surgeons and Gynecologists are Penalized for PQRS Reporting Failure…and What They Can Do

Written on July 13, 2017. Posted in Blog.

How PQRS Solutions Such as Patient Management Software Can Help Reclaim Lost 2% Payment Adjustments for Medicare/Medicaid Reimbursements

If your hospital or clinic offers orthopedic surgery or gynecology and participates in Medicare or Medicaid, it’s likely that you already are aware of harsh fact: Failure to properly submit Physician Quality Reporting System (known more simply as PQRS) reports results in a two percent reduction of reimbursements. What you may not know is more than a third of participating orthopedic surgery and gynecology practices take advantage of PQRS reporting, according to a report released by the Centers for Medicare & Medicaid Services, 2015 Reporting Experience: Including Trends (2007-2015) Physician Quality Reporting System 2017.

What is PQRS Reporting?

The PQRS reporting program is the primary means by which CMS is implementing value-based purchasing (VBP), designed to reward quality over quantity when providing compensation for services provided for Medicaid or Medicare patients. Scheduled to sunset in 2018, the PQRS program measures quality via reported medical measures taken by qualifying physicians. Initially created with 74 reportable measures, the number of reportable measures and means by which a physician can report them has increased yearly based on participant feedback. As of 2015, there were 253 measures that could be reported to the system. Beginning in 2015, the PQRS program was also used to determine whether physicians receiving funds would be subject to a payment adjustment: a penalty of two percent. Physicians that did not participate in the program—or failed to report the required number and percentage of measures—were subject to the adjustment. Although the PQRS program is sunsetting in 2018, the focus on VBP is continuing. The PQRS program is being replaced by the Merit-based Incentive Payment System (MIPS), which retains many of the features that were present in PQRS, while also implementing a volume threshold.

PQRS Reporting Failure

PQRS reporting failure was, by far, the most common reason that physicians were subject to the payment adjustment in 2015. Of those that did report, reporting via electronic health records (EHR) resulted in the fewest percentage of payment adjustments, with only four percent receiving adjustments via that reporting method. This finding by CMS is in line with one of the primary goals of PQRS and MIPS: to increase the use of EHR by physicians to provide higher quality care for patients. According to the CMS report, this type of reporting was uncommon, with the highest percentage of use coming from:

• Ophthalmologists (25.4%)

• Orthopedic surgeons (11.5%)

• Gynecologists (11.3%)

While the initial report only covered 2007–2015, some additional statistics were provided for 2017 in the final release of the report. The most important statistic is the percentage of physicians subject to the penalty due to failing to satisfactorily report measures taken, broken down by specialty, which included:

• Orthopedic surgeons (32.4%)

• Gynecologists (36.8%)

Both numbers represent a slight decrease from 2015, but still mean roughly a third of physicians in these specialties are being penalized.

PQRS Solutions

The fact that PQRS reporting methods correlate significantly with being subject to the penalty suggests it isn’t the standard of care lacking among most physicians being penalized, but rather that administrative abilities are lacking. That is a dilemma that can be solved in part with healthcare management systems and other healthcare IT PQRS solutions. The first step, if not already taken, is clearly to use EHR in daily practice. Use of EHR is both a factor in determining whether a practice or individual should be penalized and is strongly correlated with better quality of care for patients. The next step to improving the quality of reports is improving patient management. Streamlined administrative procedures will result both in better outcomes for patients and in reported measures that are more likely to pass muster.

Professional Patient Management

Once MIPS becomes the dominant program in 2018, every practice will need to provide quality care, have strong administrative practices, use EHR, and serve large numbers of patients. Although quality of care is entirely the responsibility of the physician, those other factors require professional administrative experience. It is a task that is simply beyond a single physician or administrative assistant. It is a task that requires a highly experienced team of professionals using patient engagement technology, like the Sequence healthcare SaaS (software as a solution). The best way to satisfy MIPs and avoid the penalty is to use the services of a patient management platform. A good patient management platform assists with all administrative functions, including patient acquisition and patient retention. This platform becomes an extension of the administrative staff of the practice, answering questions, verifying insurance, and providing reminders throughout the care of patients. Overall, this service eases the administrative burdens on physicians allowing them to provide higher quality care to a larger pool of patients, both of which will be essential requirements to avoiding the penalty starting in 2018.

Good PQRS Reporting Requires Modernizing

The conclusion of the CMS report is clear: Familiarity with the PQRS reporting system offers slight benefits, but modernizing offers the best benefits. Physicians that use electronic health records and incorporate outside administrative assistance are vastly more likely to avoid the penalty than those that don’t, because those physicians are providing higher quality care to their patients. And since the costs involved in modernizing are almost always countered by an increased patient base, there is little reason not to modernize.

As Guideway Care Central/Western Regional Director, Chris Stearns is not only one of our healthcare IT experts, but he also provides specialized focus on Orthopedic Surgery and Women’s Health. Guideway Care is a cloud-based technology and services company that improves profitability and patient outcomes for hospitals and practices through end-to-end patient engagement solutions backed by clinical and non-clinical teams. Its HIPAA-compliant, SaaS platform improves care team workflows, automates patient communication and tracks patient progress to optimize the patient journey. Since 2004, leading healthcare providers have trusted Guideway Care to help acquire, manage and engage patients through complex episodes of care.

What’s Up With CMS’ Cardiac and CJR Bundled Payment Delays?

Written on March 22, 2017. Posted in Blog.

An Overview of Facts and Opinions About CMS Delays for Cardiac and CJR Bundled Payments from Leading Healthcare Voices

Yesterday, healthcare news and blog outlets were virtually tripping over each other to announce the Centers for Medicare & Medicaid Services’ decision to delay two bundled payment program deadlines. CMS’ first delay relates to Cardiac Care. In short, CMS changed the original July 1, 2017 effective date for mandatory bundled payment programs for heart attacks and bypass surgeries to October 1, 2017.

[poll id=”3″]

The second relates to Comprehensive Care for Joint Replacement, a topic that we’ve been discussing for months—including a recent blog, “Bundled Payments and CJR Among Key Topics of Interest at ACPM’s 2017 Orthopedic Value Based Care Conference.” CMS is delaying the expansion of the CJR bundled payment program from the original July 1, 2017 date to October 1, 2017. If that explains the “what” and “when” factual reasons for the delay, what about “why”? CMS’ announcement explains it is to:

• Extend review time

• Potentially modify the policy

• Ensure participants understand the policy

However, there is much more being said about the delays, especially from the aforementioned healthcare news and blog outlets that have cast some compelling analyses. For instance, Healthcare DIVE.com speculated “the recently released interim rule casts doubt on the future of bundled payment initiatives,” even after President Donald Trump’s February 2017 executive order to delay the new rules. The reason for the sudden doubt is that, according to the American Journal of Managed Care:

“…even if the coverage elements of the Affordable Care Act (ACA) are repealed, payment reform would move forward under the Trump administration, in part because Republicans voted overwhelming with Democrats for the Medicare Access and CHIP Reauthorization Act (MACRA).”

The delays are also possibly having real-time impacts for healthcare providers not expecting delays, much less potential rollback of the programs. As Managed Health Care Connect.com suggested:

“Although CMS originally envisioned the bundled-payment programs would help clinicians accrue incentives under the Alternative Payment Model, delays may have implications for providers who were hoping to use the bundled payment models during their MACRA verification.”

In sum, the confusion about the health of current and proposed CMS programs—especially those closely tied to the Affordable Care Act—is and was to be expected, which we touched in at the beginning of the year in our blog, “How Might Repealing Obamacare Affect Medicare Reimbursements?.” And, as stated in that blog, the best advice is perhaps to “do what you can now to ensure the best outcomes for your Medicare patients, which can be improved with a reliable and efficient patient management system.”

Derek Rudnak is a freelance healthcare marketing content creator that frequently contributes exclusive blogs to Guideway Care.

Three Key Metrics To Control Post-Acute Care Costs And Optimize CJR Reimbursements

Written on January 27, 2017. Posted in Blog.

After spending last weekend with a group of clinicians, administrators and healthcare executives at the Interdisciplinary Conference on Orthopedic Value-Based Care, one thing is clear: Bundled payments implemented by Medicare’s Comprehensive Joint Replacement program are shaking up the foundation of how every stakeholder must address joint replacement therapy. The Comprehensive Joint Replacement Program represents much more than reimbursement reform — value-based care is transforming how healthcare is delivered, leaving many wondering how to best position themselves to maximize revenue and mitigate risk. With so many stakeholders involved, it seems extremely complicated to identify and manage the drivers of expenses that CJR seeks to control. The first step to a sound bundled payment strategy begins with an examination of current processes and realignment to create a multi-disciplinary and team-based system of coordinated care that is centered around the patient. Then, the data shows that most of the variation in episode costs, and thus the opportunity for improvement, can be tracked to post-acute care (PAC) utilization. Optimizing this portion of the episode is a key focal point for hospitals operating under CJR regulations, and tracking metrics associated with this recovery period is core to any successful CJR strategy. There are three important metrics related to PAC that should be analyzed to help identify and eliminate the barriers to maintaining healthy margins when subject to bundled payments for joint replacements.

Percentage of patients discharged directly to their homes – It’s fairly obvious that patients discharged to private homes cost much less than those that require institutional post-acute care, so tracking that data is imperative. As a rule of thumb, hospitals that discharge 50 percent or more of joint replacement patients to their homes are healthy programs. Increasing this metric over time will require coordination with all stakeholders. Dashboards are effective tools to tracking this important driver of success.
Length of stay in institutional facilities – PAC spending accounts for 44 percent of total episode costs for knee replacements, and length of stay in skilled nursing facilities (SNF) is the largest driver of that cost. Tracking this metric in the aggregate is important, but also examine average length of stay by facility, particularly for your largest volume SNF’s, and look for variations. This data will help you make informed decisions about your network and engage with your partners to reduce unnecessary costs.
Hospital readmission rates – Hospital readmission rates vary considerably among diagnoses, and knee replacement surgery is fortunate to enjoy low rates with an average of only 7 percent. Targeting a readmission rate of 5 percent or less is a worthy goal. However, you need to also examine the costs of your readmissions, which is available in the data the Centers for Medicare & Medicaid Services provide to CJR hospitals. It is possible to have a low readmission rate, but high readmission costs due to catastrophic readmissions. Parsing the data on readmission rates and costs will help pinpoint issues that you can then go tackle.

With the five year long trial of Comprehensive Joint Replacement Program bundled payments not even a year old and uncertainty surrounding the future of healthcare policy with the newly elected administration, many healthcare providers have not begun learning how to best comply with these changes. As of now, CMS remains committed to using alternative payments for 50 percent of all Medicare reimbursement by next year, and most hospital leaders believe value-based care is here to stay. It makes sense to begin planning for this eventuality because it involves redesigning processes and care delivery, and results in better outcomes and a better patient experience. At Guideway Care, we believe that simple low-cost technology solutions that provide real-time insight into how patients are recovering from surgery are beneficial to all healthcare providers, whether they are working within CJR requirements or simply dedicated to providing the highest quality care and reducing expenses. Let us show you how you can increase patient satisfaction, lower costs, and position for value-based care changes associated with Comprehensive Joint Replacement program.

How Might Repealing Obamacare Affect Medicare Reimbursements?

Written on January 5, 2017. Posted in Blog.

Keeping up with the latest changes to Medicare reimbursements—whether they are actual changes, proposed changes, or just speculation—is always a challenge. However, with a new Presidential administration preparing for when President-elect Donald Trump is sworn-in in a couple weeks, the rumors are definitely more intense than ever…especially after Trump’s campaign promise to repeal the Affordable Care Act (“Obamacare”) immediately after he is inaugurated.

However, that poses yet another challenge for healthcare administrators that are affected by Medicare reimbursements: Along with simply keeping up with the headlines and reactions, there is the added complexity of not being distracted by partisan politics and other subjective anticipations or interpretations.

In that context, here is a digest of expectations, analyses and non-partisan opinions about potential changes to Medicare reimbursements in 2017 and beyond.

[Tweet “…here is a digest about potential changes to Medicare reimbursements in 2017 and beyond.”]

Repealing Obamacare: Will It Happen?

It’s almost impossible to discuss the Medicare reimbursements without address the potential for ACA being repealed. Prior to the election, there was no doubt about Donald Trump and Mike Pence’s intentions to repeal Obamacare. In fact, their campaign Website’s position statement, “Healthcare Reform to Make America Again” made it crystal clear:

“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.”

However, since the election, things have become less certain. In its statement, “TrumpCare Explained”, ObamacareFacts.com said:

“However, after a meeting with President Obama [shortly after Trump won the election], President-elect Trump has suggested he will either amend ObamaCare or repeal and replace it.”

Yesterday, the LA Times article “Obama and Pence Visit Capitol Hill to Rally Opposing sides on Obamacare” said that “It’s unclear what, exactly, Trump is recommending” and that “Republicans are in a bind over their efforts to repeal the law.”

However, it is a Law360.com article, “Health Care Policy to Watch in 2017” that perhaps provides the most concise explaination of what to expect with Obamacare:

“Experts say the end result is anyone’s guess.”

One reason that is is so difficult to find a solid answer to the “Will Obamacare be repealed?” question is because it is closely tied to two other questions: When would it be repealed and what would replace it?

“It might take as many as three more years to unwind the gears of the Affordable Care Act, especially when it comes to Medicare,” according to the FiscalTimes.com article “Trump’s Dilemma: Can He Repeal Obamacare Without Killing Medicare?”

Law360.com further suggests that the answers are murky because of the potential of a “repeal and delay” approach where Congress could repeal Obamacare immediately, “but delay the effective date of repeal by a few years—without simultaneously passing a replacement law.”

Repealing Obamacare: If It Happens, What Happens to Medicare Reimbursements?

[Tweet “For the sake of argument, assume that indeed Obamacare is repealed. What happens?”] For the sake of argument, assume that indeed Obamacare is repealed. What happens? One thing is certain: It will affect Medicare reimbursements. The Forbes.com article “How Trump’s Plan To Gut Obamacare Will Take Down Medicare.” explains:

“Although Trump said during the campaign that he wouldn’t touch Medicare or Social Security—he wouldn’t have secured enough Electoral College votes if he had—tearing apart Obamacare will almost certainly raise costs for Medicare beneficiaries and hasten its decline as a guaranteed, fee-for-service system.”

Of course, there are varying opinions about the potential impacts. For instance, it may mostly be a matter of disruption for healthcare administrators, according to a HealthcareITNews.com article with a very self-explanatory title, “ACA Repeal Could Make ACOs, MACRA, Medicare Shared Savings and CMS CMMI More Complicated”.

Another suggested impact is that reducing or elminating Medicare (and for that matter, Medicaid) funding will trigger a series of events that may result in financial losses into the billions for hospitals, according to The Hill.com in its article “So What Would Happen If We Repealed ObamaCare?”:

“If you remove tens of millions of people from the rolls of the insurance carriers because subsidies are eliminated and Medicaid expansion is defunded, if young adults ages 18 to 26 lose coverage, as well as those with pre-existing conditions, where do those who lose coverage go for care? As you might have guessed, it is your local hospital emergency room. This will result in tens of billions of dollars in uncompensated care being provided by our hospitals. Prior to the enactment of ObamaCare, uncompensated care provided by hospitals in our communities was in the range of $75 billion to $125 billion.”

For the moment (and perhaps for the next months or even years), Medicare is still here, and for that matter, so are new programs such as MACRA, which was rolled out days ago on January 1, 2017). In as much as you should be prepared for changes to Medicare reimbursement for whenever they occur (and for whatever reasons), it’s even more important to do what you can now to ensure the best outcomes for your Medicare patients, which can be improved with a reliable and efficient patient management system.

[Tweet “…do what you can now to ensure the best outcomes for your Medicare patients…“]

If your facility seeks proven, qualified guidance and support to successfully participate in the MACRA rollout, please contact Guideway Care to learn about our solutions.

BPCI Initiative Year 2 Lessons Learned

Written on November 29, 2016. Posted in Blog.

Top Results from CMS’ Bundled Payments for Care Improvement Initiative Progress Report

The Centers for Medicare and Medicaid recently published CMS Bundled Payments for Care Improvement Initiative Models 2-4: Year 2 Evaluation & Monitoring Annual Report. If you have been following the recent developments of either the BPCI initiative or the Comprehensive Care for Joint Replacement mode (CJR), you are likely aware of their functions and similarities. If not, here’s a quick overview. First, the BPCI initiative is a voluntary pilot program that is testing an alternative to the traditional fee-for-service reimbursement model that pays a hospital or clinic whenever it provides treatment—regardless of outcome. Bundled payments, on the other hand, link all healthcare providers for an episode—such as hip or knee replacement surgeries that involve various treatments—and then evaluates outcomes of cost and performance. CJR was introduced earlier this year to test a new reimbursement model for Medicare hip and knee replacement surgeries. Also known as lower extremity joint replacements (LEJRs), it is one of Medicare’s most common inpatient surgeries. Both BPCI and CJR are designed to reward hospitals (or participant physician groups, in the case of BPCI) for improving care coordination and achieving cost savings aligned with a target price determined by CMS based on the participant’s historical performance. When the hospital reduces episode costs below the target price, they receive a share of the savings. If payments remain above the target price, the hospital may owe a reconciliation payment to CMS. Since the CJR program and the BPCI initiative are similar in structure and design (with 83 percent of BPCI episodes included in the CMS report identified as orthopedic episodes) there are lessons to be learned in the report and applied to organizations affected by CJR and other burgeoning bundled payment initiatives. Some top takeaways:

Post-Acute Care Management is Key to BPCI Episode Spending

BPCI initiative participants that saw the most reduction in episode spending were those that achieved a marked decrease in SNF (skilled nursing facility) utilization, some up to almost five percent reduction compared to baseline.

BPCI Care Quality is Not Suffering

The BPCI initiative has its share of critics that are justifiably concerned about its potentially negative impacts on quality. However, the orthopedic BPCI data is thus far indicating that quality outcomes have remained high for participants, with no significant changes from baseline.

BPCI is Resulting in Episode Payment Savings

This early data shows that almost 90 percent of BPCI participants achieved a decline in episode payments. There has been an estimated $2000 per-episode average decline in payments correlated with appropriate utilization of post-acute care facilities and decrease in length of stay, among other factors.

Patient Management Proving to be Crucial BPCI Success Factor

Those that are targeting patient management resources are seeing the successes outlined above. This includes: • Workflow redesign • Care coordination • Case management • Patient navigation Although there is still not a universally agreed upon set of best practices for patient management and BPCI success, the data is indicating that a combination of activities are pulling healthcare providers in the right direction, such as: • Leadership buy-in • Resource allocation • Patient-centered care teams With these lessons learned from the BPCI Year 2 Evaluation, do you have the tools you need to be successful in CJR? Contact Guideway Care to learn how you can optimize the patient care coordination process using the Sequence platform.

How are MACRA and CJR Connected?

Written on November 22, 2016. Posted in Blog.

Most people involved in healthcare—especially as it relates to Medicare reimbursements—are generally familiar with with MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and CJR (Comprehensive Care for Joint Replacement). However, what might they might not fully understand is how MACRA and CJR are connected. The simplest answer is that MACRA and CJR are connected by the Centers for Medicare & Medicaid’s goals for improving outcomes and reducing costs through value-based reimbursement and bundled payment models rather than the traditional fee-for-service model. A critical path for achieving this is to ensure that your hospital or clinic is prepared for better patient communication and management. However, to more fully understand the connections between MACRA and CJR—and how patient management technology fits in—it’s best to first briefly examine these concepts and what they strive to change or improve.

Fee-for-Service vs. Value-Based Reimbursement Care Models

More thorough examinations of fee-for-service vs. value-based reimbursement care models can be found on this blog and throughout the Internet. But most simply, the key differentiator between fee-for-service and value-based care is the difference between “quantity vs. quality,” respectively. The fee-for-service model rewards healthcare providers based how many patients and treatments a healthcare provider sees and provides (read: quantity), as where the value-based model rewards providers based on how well it treats them (read: quality)—as determined by CMS standards that include outcomes and satisfaction.

What is MACRA?

Enacted by the U.S. Congress in 2015, MACRA is a value-based payment system (also known as a “quality payment program”) to be associated with Medicare services. More can be learned about MACRA’s quality payment program rollout for January 2017, but one of its primary features is the introduction of two payment tracks:

• Merit-Based Incentive Payment System (MIPS)

• Alternative Payment Models (APMs)

Another primary MACRA feature will be the replacement of three existing quality reporting systems with a streamlined, more effective alternative.

What is CJR?

CJR was introduced earlier this year to test a new reimbursement model that encourages and rewards efficiency and satisfaction for Medicare hip and knee replacement surgeries. Also known as as LEJR (short for “lower extremity joint replacements”), it is one of Medicare’s most common inpatient surgeries.

Putting It All Together: Linking MACRA, CJR and Value-Based Care

LEJR treatment and recovery requires care from a spectrum of caregivers, including hospitals and post-acute care. Rather than reimbursing each with the fee-for-service model, CJR utilizes a “bundled payment” model for each “episode”—which is designed to encourage all caregivers to work together towards the same goals for which MACRA is intended:

• To reduce visit frequency and in-patient procedures

• To increase satisfaction, rewards, and patient-reported outcomes

Those that are prepared for the MACRA/CJR transition will be better positioned to be rewarded economically; those that aren’t may be penalized. A crucial factor for being well positioned is to have technologies and systems that can streamline patient care coordination with workflow management. Are you prepared to deliver and document value-based care to ensure you maximize your earning potential under reimbursement models that feature bundled payments? If not, contact a Guideway Care representative to learn about our CJR bundled payment program solutions.

Easing MACRA’s Quality Payment Program Transition

Written on November 17, 2016. Posted in Blog.

As the highly anticipated Quality Payment Program—a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—rollout begins, so does the search for solutions for easing the transition. Although MACRA’s enactment and the corresponding transition to the Quality Payment Program offer significant advantages to many U.S. healthcare facilities, it may also represent a costly shift in existing infrastructure for others. This is especially true for hospitals that are not equipped to track the necessary metrics for one of the Quality Payment Program’s payment tracks.

What is MACRA and the Quality Payment Program?

Drafted by the Centers for Medicare and Medicaid Services (CMS) as an alternative to traditional payment and reimbursement policies, MACRA is an extremely complex piece of legislation that seeks to accomplish the weighty task of implementing value-based care. While perhaps too lengthy to read in full for most busy healthcare professionals (the document itself is more than 2,000 pages), understanding its fundamentals is crucial for any healthcare facility that provides treatment for Medicare and Medicaid patients. Most simply, MACRA is an incentive-based payment system to be associated with Medicare services. Physicians will no longer utilize the fee-for-service model or the Medicare Sustainable Growth Rate formula (SGR) that has been used since 1997 to calculate payment. Instead, they may now choose from two new payment tracks—which, when used in conjunction, can better achieve a results-oriented method:

• Merit-based Incentive Payment System (MIPS): In an effort to accomplish a truly effective merit-based model, MIPS consolidates three existing quality considerations (i.e., meaningful use, Physician Quality Reporting System, and Value-based Payment Modifier) with a new evaluation method: clinical practice improvement activities. These criteria are then used to determine a score from 0–100 that can be applied to physician payments.

• Alternative Payment Model (APM): A secondary method, APM is designed to further enhance what MIPS is able to accomplish by offering practitioner bonuses for continued excellence. Exact practices vary from one facility to the next, but qualifying participants must meet certain requirements, including:

• Use of certified EHRs

• Payments under an approved quality-based system

• Services that assume more than a nominal risk of losses

MACRA is also designed to replace three existing quality reporting systems with a more streamlined and effective alternative. Although this is intended to reduce clinical administrative burdens in the long run, it may require a better approach to patient management in the interim.

Sequence Patient Tracking System: A Solution for Reducing MACRA Admin Burdens

The Sequence Patient Tracking System can ease your healthcare facility’s transition to the Quality Payment Program tracking patients from first contact to recovery. By collecting and consolidating all necessary information through a HIPAA-compliant platform, our lead and patient tracking solutions enable you to manage patient leads, streamline patient intake, and organize patient information. If your facility seeks proven, qualified guidance and support to successfully participate in the MACRA rollout, please contact Guideway Care to learn about our solutions.

Fee for Service vs Value Based Care in Healthcare Payment Reform

Written on September 30, 2016. Posted in Blog.

Payments in the medical world have long been a point of debate, especially as the cost of health care continues to rise. Fee-for-service payment structures have historically been the norm, allowing physicians and medical centers to bill for each appointment, test, and procedure performed. However, as quality of service evolves and demands for standards of care increase, so do the possibilities for payment. Lead by CMS, or Centers for Medicare and Medicaid Services, the medical culture in the United States is moving away from its roots and into a new era of value-based pricing. Deviating from traditional norms is generally a challenge, especially for hospitals whose staff and technology support fee-for-service care. However, with support from the right software platform, it’s possible to bring any medical facility into the new horizon of patient-focused care.

Fee-for-Service

In the wide world of medical payments, fee-for-service has been the standard throughout much of the modern world of medicine. Under this systems, billing and payments are determined based on the procedures performed by a doctor as opposed to the outcome achieved through medical care. While initially a strong concept, the current climate has shifted. Increasingly, physicians are feeling pressure to perform ancillary testing and optional procedures for the purpose of billing insurance companies rather than generating results.

Value-Based

As the name implies, value-based care is assessed, and rewarded, based upon the value practices and procedures offer patients. Instead of taking a numbers-based look at the services performed, value-based healthcare delves deeper, providing payments based on successful outcomes and healthy patients rather than the number of procedures used to get there. With a marked emphasis on lower costs of care and reduced time spent in in-patient facilities, this approach attempts to qualify, not quantify, the medical climate in the United States. While value-based systems are still in their infancy, numerous medical bodies, including CMS, are pushing for complete industry reform.

Deciphering the Difference

In an ideal world, fee-for-service and value-based systems will not at odds with one another, but rather working in tandem to provide the best possible patient experience. For example, a standard annual physical cannot necessarily be evaluated in a value-based manner, requiring a fee-for-service approach. These changes are instead intended to provide a uniform standard of care in surgical and procedural cases, such as CMS’s proposed Comprehensive Care for Joint Replacement program and the passage of the Medicare Access and CHIP Reauthorization Act of 2015.

Making the Transition

With countless medical records platforms and billing systems built around a fee-for-service model, incorporating value-based payment bundles into a practice can be exceptionally daunting. Transitioning away from fee-for-service may be beneficial in the big picture, reducing patient stay durations, costs of care, and penalties from payers, but the implementation process can be both time consuming and costly. Rather than facing extra fees and billing complications, the right software support system can ease the burdens of applying a new approach to billing and payment collection.

View our archived webinar: How Sequence Can Help You Succeed in the Balance of Volume-based and Value-based Outcomes by Measuring these Four Pillars of Care

Guideway Care specializes in meeting and maintaining the needs of medical practices and hospitals of all shapes and sizes, ensuring a simple transition for your needs. By streamlining the changeover, reducing paperwork, and saving time, our proprietary system can assist you in taking your healthcare into the future. When you’re ready to adopt value-based payments as a part of your practice, Guideway Care can make the process as easy and possible. Contact us today to learn more about our unique approach to medical innovation. Guideway Care Sequence of Activation Phone: 888.986.3638 Fax: 770.234.3815 Email: info@sequencehealth.com

Know Your Earning Potential with Bundled Payments and Value-based Care

Written on September 15, 2016. Posted in Blog.

The increase in value-based care initiatives tied to bundled payments indicates big changes in the healthcare industry that affect the way patients receive care and providers measure success. As technology and medicine continue to advance, so does the way doctors engage patients to create meaningful relationships resulting in better patient outcomes. Traditionally in the United States, payment for healthcare treatment has been based on a fee-for-service model – the more patients receiving service, the more reimbursement for the provider, but that model is quickly changing. Hospitals, practices, and even clinicians are now paid according to value-based care reimbursement models. Quality and outcome standards are used to determine pay rates in response to a need for care that improves health rather than demands services. Organizations, and even individuals, are rewarded for meeting target costs and improving patient satisfaction and outcomes, while penalties are assessed for those unable to meet standards set by CMS. Guideway Care offers a suite of solutions allowing doctors and patients alike to benefit from new standards in efficient care delivery, effective patient experiences, and payment models that make sense under today’s value-based care programs.

What Is Value-Based Care? Historically, doctor’s services are charged on a per-procedure or appointment basis. As such, many doctors feel pressured to perform a long list of procedures and tests that may or may not be necessary. In time, this cycle leads to longer patient hospital stays, more patients at one time, and often unnecessary ancillary testing. Instead of putting pressure on healthcare providers to perform potentially-needless procedures, value-based care focuses on medical decisions with the patient’s health and best interests in mind. When properly incorporated, this approach to medical treatment can ultimately reduce visit frequency and in-patient procedures while increasing satisfaction, rewards, and patient-reported outcomes.

CMS Leads the Transition to Value-based Care For facilities that work with Medicare, complying with value-based mandates may or may not be required by CMS, or Centers for Medicare and Medicaid Services. CMS currently oversees a number of value-based bundled payment models, including CJR that affects orthopedic practices in 67 different regions across the country, and will be rolling out the new MACRA incentive-based payment system in 2017. Comprehensive Care for Joint Replacement (CJR) Commonly known as CJR, Comprehensive Care for Joint Replacement seeks to address one of the most common orthopedic inpatient procedures for Medicare patients: knee and hip replacements. Designed in an effort to standardize quality and cost of care, CJR replaces fees for related services with a bundled payment method, regulating the procedure, recovery duration, and more. Medicare Access and CHIP Reauthorization Act (MACRA) Passed in 2015, the Medicare Access and CHIP Reauthorization Act, or MACRA, is an incentive-based payment system to be associated with Medicare services. Utilizing two tracks for payment, Merit-based Incentive Payment System (MIPS), and Alternative Payment Models (APMs), MACRA is intended to replace three existing quality reporting systems with a streamlined, more effective alternative.

Leveraging the Sequence Platform By treating healthcare technology as a tool, not an industry, it’s possible to increase quality of care while reducing paperwork and honing the focus on paying for what works rather than what can increase billing. Guideway Care can streamline this transition, easing the workflow impact of physician teams and making workflow management, patient engagement, and care plan adherence painless. With our unique technology related to hospital and provider management, our suite of solutions alleviate your burden, increase efficiencies, and simplify your care team’s day-to-day routine. Are you prepared to deliver and document value-based care to ensure you maximize your earning potential under reimbursement models that feature bundled payments? Contact Guideway Care today to learn more!

Guideway Care Acquires Waypoint Healthcare Solutions to Expand Enterprise Patient Activation Intelligence Solution

Guideway Care Acquires Waypoint Healthcare Solutions to Expand Enterprise Patient Activation Intelligence Solution

Evidence-Based Patient Activation Overview

Nurse Triage

Medical Contact Center

Patient Care Coordination

Appointment Scheduling

After-Hours Support

Insurance Verification

Care Management

How We Deliver Patient Activation

Activation Intelligence Orchestration

Motivational Patient Guidance Framework for Activation Success

Guideway Care Acquires Waypoint Healthcare Solutions to Expand Enterprise Patient Activation Intelligence Solution

Evidence-Based Patient Activation Overview

Patient Activation

Barrier Resolution

Intelligent Orchestration

AI-Enhanced Patient Activation

Guideway Care Acquires Waypoint Healthcare Solutions to Expand Enterprise Patient Activation Intelligence Solution

Topic: Risk-Based Contracts & Cost Performance

Medicaid Coverage Risk Calculator

What Could Medicaid Coverage Loss Cost Your Health Center?

Your Risk Scores Don’t Reflect the Patients You’re Treating

Your RAF Scores Are Artificially Low

You’re Missing the Most Consistent Touchpoint You Have

CCM calls happen monthly. Office visits happen a few times a year.

Incomplete risk data distorts your entire population health picture.

The gap widens as value based contracts expand.

RAF Documentation Built Into Every Touchpoint

Complete ICD-10 Z code capture at every interaction

Your medical record gets updated, not a separate database

Evidence based, condition specific workflows

Audit ready from day one

CCM reimbursement going uncaptured alongside the RAF gap

Open quality gaps that the same undocumented patients are driving

Complete documentation at every touchpoint

Stop leaving risk adjustment revenue on the table

The CCM Revenue Sitting in Your Patient Panel

Your CCM Revenue Is Theoretical Until Someone Captures It

The Revenue Gap Is the Symptom. The Deeper Issue Is What Uncaptured CCM Means for Your Entire Chronic Population.

Every month without CCM outreach is a month of unmanaged chronic disease.

Uncaptured CCM also means uncaptured risk adjustment data.

The competitive exposure is growing.

We Capture the CCM Revenue Your Panel Supports

Eligibility analysis and enrollment

Structured monthly outreach

Complete billing capture

White labeled under your brand

EHR integrated

Clinical staff stretched too thin to sustain monthly outreach

Incomplete risk adjustment documentation compounding revenue loss

Open quality gaps dragging payer performance scores

Built to capture every billable minute

See the CCM revenue in your patient panel

Your Problem

You can’t staff five programs with one team

Siloed programs create siloed outcomes

Revenue leaks at every seam

As Healthcare Experts, We See the Deeper Problem

Care management without activation is just documentation

Five programs running independently cost more than five programs running together

Your highest acuity patients carry the most uncaptured value

One team. One integration. Five activated programs.

Activation psychology at every touchpoint

Single EHR integration, five programs

White labeled under your brand

Connected patient journeys, not siloed programs

Full billing capture across all codes

Connected care management across every stage of the patient journey

Principal Care Management (PCM)

Annual Wellness Visits (AWV)

Transitional Care Management (TCM)

The patient journey, not the billing code, drives the model

TCM Outreach

TCM + RPM

CCM + RPM

AWV

Results across every care management program we deliver

$192,060

Your Members Need Care.
They’re Getting It Out of Network.

Your Members Have Chronic Conditions.
Your RAF Scores Don’t Reflect It.

Your Members Know About the Gap.
They Just Don’t Close It.