Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.

Can you give us the most common coding problems that you’ve found?

 As I have worked with providers across the country, I’ve found many challenges in medical coding of CPT and ICD-10 codes. Each time I work with a new office, I find that the same questions and problems are shared by all of us. I’ve broken down those challenges that seem to cause sleepless lights.

When it comes to ICD-10 coding, a coder’s job is to code to the highest level of specificity. This means detailing and abstracting the most information out of the medical reports from the provider and taking accurate notes. It also means knowing the medical terminology for both procedures and diagnoses. Be sure to check your ICD-10 book to ensure that each code assigned has the required number of digits, or it can lead to a rejected or denied claim.

Of course, not coding to the highest level isn’t always the coder’s fault. In certain cases, the provider hasn’t documented enough specific information for a diagnosis or procedure. Providers may leave important details in their note that are needed to correctly choose a diagnosis, service or procedure.

This problem is exacerbated by the next trouble spot on the list.

Ideally, every coder would be in constant contact with the provider they’re coding for. Unfortunately, that’s not always the case. Providers aren’t always available to consult on difficult-to-understand claims, and it might take some time to clarify the coding issues. If you aren’t able to query the provider, less-specific or unspecified codes might need to be billed, which could lead to denials.

Failing to Use Current or Updated Code Sets

The organizations that maintain the three principal medical coding code sets (the World Health Organization (WHO) for ICD, the American Medical Association (AMA) for CPT, and the Centers for Medicare and Medicaid Services (CMS) for HCPCS) update these manuals yearly. The ICD book is updated October 1, and the CPT and HCPCS books are updated January 1 each year. It’s up to coders to learn any new, revised or deleted as they come out and use them correctly. This is partly why professional organizations like the AAPC and AHIMA require every member to complete a certain amount of educational credits every two years. Keeping your skills sharp is imperative.

Undercoding occurs when codes fail to capture all work performed. This is often due to oversight, but some practices intentionally undercode to avoid an audit. This is not recommended because it results in substantial lost revenue and creates skewed claims data that ultimately lower reimbursement rates.

Overcoding occurs when reporting CPT or HCPCS codes that result in a higher payment than warranted for services provided. Whether intentional or unintentional, overcoding is inappropriate or even fraud and can trigger an audit.

Unbundling means separately coding procedures that would normally be included in one umbrella code. This can be due to either a misunderstanding or an effort to increase payment. Unbundling is closely related to upcoding, in that it involves false reporting designed to earn the provider a higher payout from a payor. Be sure to check the Correct Coding Initiative to see if two CPT codes can be billed together and read the description of each CPT code thoroughly to avoid unbundling.

Articles

Dodge these common problems with medical coding.

Medical coding common problems

, a revenue cycle management company that helps practices boost their practice performance & increase their revenue through custom billing solutions. Drop an Email to Hari 

The shifting procedures and regulations in the medical billing processes in the healthcare industry has led to scores of physicians undergoing financial crises. However, when you know what the challenges are, it becomes easy to tackle them, right? Let’s glance through the common and real-time challenges faced by the physicians with the medical billing processes, shall we?

if you want to reap the benefits of the medical practices, it is crucial to stay afloat with the changes which take place. Medical specialty specific billing requires special handling, authorization and pre-certification to carry out the complex tasks. Such specialized and focused medical billing processes also require knowledge, to streamline the process and gain faster reimbursements. However, not all physicians have that much amount of time and knowledge to keep up with the changes and dive in-depth with the detailed process. Absence of knowledge leads to nothing but errors in claims, resulting in denials.

HIPAA Laws have been created to protect the privacy and data of the patients, which needs to be adhered to by the healthcare settings. However, these confidentiality laws are subject to constant change which leads to heavy penalties in case not met properly. Physicians fail to keep a track of the changing confidentiality laws which loops them in deep-trouble.

As per the Becker’s Hospital Review, 80% of the medical bills have errors. Medical settings are making a shift towards computer-assisted-coding ; however, there is still scope for humans to make errors. Such typos lead to the claim denials. Thus, it is advised to the physicians to onboard people with years of expertise or simply outsource the medical billing process.

The understanding of the digital documentation is very significant for a medical coder to ensure a smooth billing process. However, a lot of medical settings fail to renew their professional credentials and train their staff with the latest updates, which creates a loophole in the entire medical billing system.

This is one of the most faced challenges by the physicians in the medical billing processes. The revenue management cycle requires the claims to be tracked through its complete lifecycle, thus the medical coders and billers need to pinpoint the errors. In case these errors are not resolved rapidly, it leads to loss in revenue.

 To gauge an understanding of the new coverage policy, the payers require an ample amount of time. This leads to confusion, resulting in denial of claims due to minor errors, complicating the entire process for the medical billing system.

As per the Cincinnati Enquirer, over 411,000 seniors have faced double-billing for their medical billing. This happens because physicians undergo a lot of stress in the medical settings due to the nature of the profession they have. Apart from taking care of patients, they need to play a role in the administrative duties, which just adds to the bucketload of stress. It is not easy to ensure smooth patient care along with the documentation process, because the latter demands staying abreast of the changes which take place in the system and being constantly up to date.

Scores of physicians’ medical settings have manual processes which leads to extension of time. Due to the absence of technological advancements, healthcare providers are not able to provide accurate and rapid response to the patients.

A lot of medical practices carry out the crucial information by hand which automatically results in errors, this leads to the claims getting denied even if there is a tiny mistake.

There is a constant stress to complete the documentation in the correct manner else the physicians are liable to lawsuits. However, this just adds up to the additional task list that the physicians need to perform, distracting them from patient- care.

 In no small measure, cyber-attacks happen in every industry and the healthcare industry is no such exception to this. Hackers have advanced technologies which may put your patient data at risk and you're breaching their privacy. Thus, to ensure patient information confidentiality, physicians must have secured firewalls to protect their system.

With the advancement of advanced technologies, the healthcare sector has skyrocketed in terms of their medical billing processes. As per the Research and Markets, the medical billing outsourcing market value will hit $8 million by 2026. However, there are still scores of physicians’ medical settings which use the traditional hand-written method for their medical billing processes. The former has led to decrease in valuable time used, administrative errors and costing. In no small measure, these advanced technologies have facilitated a simple experience and boosted patient engagement rate. Thus, if you’re battling these challenges related to medical billing processes, the best option is to outsource it to a medical billing company.

a revenue cycle management company that helps practices boost their practice performance & increase their revenue through custom billing solutions. Drop an Email to Hari 

When you know what the billing challenges are it becomes easier to tackle them.

Challenges physicians usually face with the medical billing processes

Amit Jayakar is the Vice President Commercial Operations of Fathom, a Tarsadia and Founders Fund backed company that uses deep learning to automate medical coding. At Fathom, Mr. Jayakar drives the demand generation and pipeline for the commercial organization.

Mr. Jayakar started his career as a software investor at Vista Equity Partners prior to entering the healthcare industry. His passion for healthcare service led him to build bundled payment plans for health systems to introduce them to value based models. Prior to joining Fathom, Mr. Jayakar was a Senior. Product Manager at Change Healthcare where he created API services for consumers by productizing data assets.

Mr. Jayakar earned his bachelor’s degree in Math and Economics from Georgetown University, and his master’s in Business Administration from The Wharton School of the University of Pennsylvania.

Nearly 20% of claims get denied, and as many as 60% of returned claims are never resubmitted

—translating to massive financial losses.

It’s no secret that the healthcare industry faced many challenges over the past few years. With those challenges came regulatory updates and operational changes, leading to confusion and burnout—especially for medical coders and other HIM professionals.

This ever-changing landscape, including the rapid adoption of new care delivery models, prompted a litany of new coding guidelines, making it increasingly difficult for staff to keep up. When employees are unsupported, overwhelmed, and struggling to stay up-to-date on the latest rules, mistakes are bound to happen.

Mistakes on claims lead to denials, which can become a massive financial burden if left unchecked.

the number of claims denied on the first submission by medical practices doubled in 2021

, it is now more important than ever for practices to prioritize quality and accuracy in their revenue cycle operations and, more specifically, their medical coding.

Let’s start with the basics. There are many reasons why a practice may receive a denied claim, but some of the most common reasons include:

A duplicate claim means a coder submitted a claim more than once for the same service performed on the same patient. This usually results when an HIM staff member accidentally resubmits a claim before the insurance provider has responded.

There are certain services that staff should not report separately. For example, some payers consider actions such as checking a patient’s heart rate as part of evaluation and management services. In this instance, they should only use one office visit code, even though pulse oximetry has its own CPT code. If two claims are submitted for these bundled services, also called unbundling, the payer will deny it.

Unbundling can also lead to overcoding, meaning staff submits a claim for a higher payment than allowed.

Each payer outlines filing timeframes that providers must follow. Some filing limits may be as short as 30-days and some as long as two years. If billing staff fail to submit a claim before the end of a payer’s filing limit, they’ll receive a denial and potentially have to write off those charges. With coding backlogs growing due to understaffing or lack of training, providers are more frequently encroaching or exceeding the filing limits.

Practices may receive a denial stating that a service wasn’t deemed medically necessary according to a patient’s insurance. A common reason for this is miscommunication between providers and coding and billing staff. A patient may have received a covered service, but because they had an incorrect diagnosis listed on their documentation, payers interpret it as not covered.

Missing or insufficient patient information such as birth date or insurance details happens largely because practices still use manual processes. When staff members manually go through copious amounts of patient paperwork daily, small details can go unnoticed easily.

A common denominator between all of these situations is medical coding. Whether good or bad, the accuracy of a practice’s coding greatly impacts the number of denied claims they receive.

Using AI-automated coding technology to reduce denied claims

Many practices have employed technology solutions such as AI-automated coding to combat denied claims. These solutions use artificial intelligence to act as any human coding team member—imagine having hundreds of your best coders.

There are multiple ways a solution like this can impact denied claims. The first is through AI-powered coding audits.

Coding audits are a tool that often goes unused by practices—to their detriment. Revenue Cycle Managers should use them to take stock of your current coding operations and discover the source of your denials. This information is invaluable in preventing future denials. Regular audits give practices a deeper understanding of what they can improve and what they are doing correctly.

Another way to reduce denied claims is by automating routine coding to reduce staff workload. Let AI technology take on simple coding tasks like payment posting, insurance verification, or fully coding common provider encounters and charts. This allows coding personnel to focus on the more difficult aspects of their jobs like in-depth claims or resolving previously denied claims.

When staff members don’t have to devote their time to tedious tasks, they can instead spend the time on a few demanding tasks, leading to fewer inaccuracies and thus, reducing denied claims.

Practices don’t have to accept denied claims as a regular part of their business. Using AI-automated technology to boost coding quality and accuracy and to support team members will promote a healthier revenue cycle.

Amit Jayakar is the Vice President Commercial Operations of Fathom, a Tarsadia and Founders Fund backed company that uses deep learning to automate medical coding.

When employees are unsupported, overwhelmed, and struggling to stay up-to-date on the latest rules, mistakes are bound to happen.

Using medical coding to reduce claim denials

is the Educational Program Director and a CERTIFIED FINANCIAL PLANNER

 at MEDIQUS Asset Advisors, Inc. He specializes in wealth management solutions

The way real property is titled will determine how it is transferred at death. For many physicians, owning a home or purchasing an investment property is a common tool for building wealth for themselves and eventually their heirs. Understanding the different titling options is important so that it can pass to heirs as efficiently as possible.

Real property is defined as land, and anything built on it. In general, there are six ways real property can be titled. Subject to the terminology of each state, most private residences are owned by:

Tenants by the entirety (a married couple owns property with each spouse passing it to the surviving spouse).

Joint owners with rights of survivorship (the property is owned with another person and either party will inherit the other party's share).

Revocable living trust (one or more persons can own the trust)

An entity such as a corporation, LLC, or partnership.

Tenants in common (an individual owns property with another person, but the heirs of each party inherit their own share).

After an individual’s death, the estate administration process begins. The process includes a review of the property title and subsequent distribution to the next owner. You can streamline this process by titling the property in a way that passes it to the people you wish in an efficient manner. Certain ways of titling the property will also allow it to avoid probate. Probate is a court supervised procedure of administering a deceased person’s estate. It can be a long and public process. Many families prefer to avoid probate and keep their personal assets out of the public gaze. Estate planning techniques to avoid probate depend on how you choose to hold title to the property, but sometimes probate is unavoidable.  

When a property is titled in one individual’s name, it is called sole ownership. This individual owns 100% of the property. At death, a property titled as solely owned will go through the probate process. During probate, the title will be transferred at the direction of a Will. If no Will was created, title will be transferred based on the decedent’s state of residency’s intestate succession laws. Probate cannot be avoided with sole ownership.

Owning property as tenants by the entirety is the most common way to avoid probate. However, this option is only available to married couples who live in states that recognize tenants by the entirety as a form of ownership. This form of ownership helps avoid delays by passing directly to the surviving spouse outside of the probate process.

Another form of property ownership that avoids probate is for two individuals to own the real property jointly with rights of survivorship (do not need to be married). At the death of the first owner, the other owner becomes 100% owner of the property. However, caution should be used before using this form of ownership. This method of ownership may not be appropriate if your goal is for someone other than the 2nd owner to inherit the property. Once the property passes to the 2nd owner, they have total ownership of it and can do with it as they please.

A revocable living trust is another option for avoiding probate. The benefit of the trust holding title to the real estate is that the trust document specifically addresses who will inherit the property. This removes the need to probate the property. There are additional considerations if the property has a mortgage. Generally, you must get pre-approval from the mortgage company to transfer the title of the property to a revocable living trust.

When ownership involves commercial or rental property, many owners have the goal of avoiding personal liability. A common strategy to avoid liability is to create a corporation or a limited liability company and have that entity own the real property. This provides some protection from being personally responsible for the debts or liabilities of the entity. However, this form of ownership does not avoid probate. At death, the shares or membership interests in the corporation or LLC pass through the individual’s estate and must go through the probate process. During this process, the will or the state’s intestate succession laws will determine who inherits the property.

Holding title as tenants in common will result in the property going through probate. Caution should be exercised with this form of ownership as well. To avoid contention over who inherits your share or the other party’s share of the property, it is best to discuss these issues with the other owner and the heirs. This can help alleviate any tension that may occur in the future when is time for someone to inherit the property.

To ensure that your wishes are met and to streamline the process upon your death, you should consult with your estate planning adviser about the best way to title your real property. 

Jeff Witz, CFP® welcome readers’ questions.He can be reached at 800-883-8555 or

200 North LaSalle Street - Suite 2300 - Chicago, Illinois 60601

312-419-3733 - Toll Free 800-883-8555 - Fax 312-332-4908 - www.mediqus.com

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Effective June 21, 2005, newly issued Internal Revenue Service regulations require that certain types of written advice include a disclaimer. To the extent the preceding message contains written advice relating to a Federal tax issue, the written advice is not intended or written to be used, and it cannot be used by the recipient or any other taxpayer, for the purposes of avoiding Federal tax penalties, and was not written to support the promotion or marketing of the transaction or matters discussed herein.

The information contained in this report is for informational purposes only. Any calculations have been made using techniques we consider reliable but are not guaranteed. Please contact your tax advisor to review this information and to consult with them regarding any questions you may have with respect to this communication.

MEDIQUS Asset Advisors, Inc. does not provide tax, legal or accounting advice. This material has been prepared for informational purposes only, and is not intended to provide, and should not be relied on for, tax, legal or accounting advice. You should consult your own tax, legal and accounting advisors before engaging in any transaction.

Understanding the different titling options is important so that property can pass to heirs as efficiently as possible.

Properly titled property may avoid probate

Physicians Practice definitive 10 best states for doctors 2022

Wondering where to start your practice? Curious where your state stacks up? Need something to rib your out-of-state colleagues about at the next conference? Look no further than this definitive ranking of which states in the union are the best suited for practicing medicine in 2022.

These rankings are based on six criteria using data from publicly available sources and Physicians Practice partners. The criteria are:

Looking for the other entries in this series?

Our previous full state rankings can be found 

Our physician density rankings can be found 

Our physician taxes rankings can be found 

Our malpractice insurance premium rankings can be found 

Physicians Practice averaged each state’s ranking in the six criteria. The GPCI was used to break any ties.

The cost of living ranking was based on the 

Missouri Economic Research and Information Center

, which itself based its ratings on averaging the indices of cities and metropolitan areas in each state.

The physician density rankings are based on the Association of American Medical Colleges’ 

2021 State Physician Workforce Data Report

This biennial report is based on data from the American Medical Association, the U.S. Census Bureau, the American Association of Colleges of Osteopathic Medicine, and the National GME Census.

This ranking was based on the Tax Foundation’s 

Facts & Figures How Does Your State Compare? 2022

In particular, Physicians Practice used Table 3 which ranked the states on five criteria: corporate tax, individual income tax, sales tax, unemployment insurance tax, and property tax.

The raw data used to calculate the average malpractice insurance cost was provided by the 

. That data was then averaged out by Physicians Practice.

For the quality of life metric, Physicians Practice used Wallethub’s 

 rankings which were based on adjusted cost of living, lowest annual cost of in-home services, their own taxpayer ranking, the percentage of the workforce aged 65 and older, museums per capita, theaters per capita, percentage of population aged 65 and older, life expectancy, and property crime rate.

 (GPCI) to adjust Medicare physician payments to account for geographic differences in physicians’ costs. Each GPCI corresponds to one of the three main components of a Medicare physician payment. They are: physician work, practice expense, and malpractice expense. For the purposes of these rankings, Physicians Practices averaged the three GPCI’s together for each state, and major municipalities contained in each state. The lower the GPCI, the higher the ranking. Because of the importance of these criteria, specifically practice expenses, Physicians Practice used GPCI rankings as a tie-breaker in the event of a tie.

Slideshows

Finally the definitive top 10 best states to practice medicine.

With all the useful information available on Physicians Practice, it is easy to become overwhelmed.

With this in mind, the tip of the week is a chance to reflect on some of the wisdom found all across the site. In an April 2021 story on 

doctor-patient communication’s role in mitigating medical malpractice claims

“As an independent medical malpractice insurance broker, medical malpractice claims are a common topic of conversation with my physician clients. I have heard many stories from doctors dealing with the threat of a lawsuit, ranging from the comically baseless to the likely merited. From all the stories I have heard, I’ve been able to discern a common theme: communication matters. And poor communication may be perceived or actual. From lack of follow-up to inadequate bedside manner, time and again some type of poor communication is the root cause of my clients’ malpractice woes, while the clients who prioritize correspondence with their patients enjoy better outcomes. Their anecdotal experiences coupled with study data has shown that physicians who practice thorough, almost relentless patient communication reduce their chances of being hit with a medical malpractice claim.”

 for the rest article. Be sure to come back next week for another Tip of the Week!

Your weekly dose of wisdom from the Physicians Practice experts.

Practice tip of the week: Doctor-patient communication’s role in mitigating medical malpractice claims

Jeffrey Bendix is the senior editor of Medical Economics.

Health care policy experts and institutions have long agreed that fee-for-service (FFS) medicine is wasteful, outmoded and at least partially responsible for the U.S. spending far more than peer nations on health care, but with outcomes that are no better and often worse.

Now, after years of experimenting, cajoling, and incentives, value-based payment models — those tied to patient outcomes and spending targets — seem to be gaining traction. According to the Health Care Payment Learning & Action Network’s (LAN) annual measurement of participation in alternative payment models, slightly more than 60% of health care payments in 2020 included some form of quality and value component. That is up from 53% in 2017 and 11% in 2012.

Similarly, 49% of practices responding to the American Academy of Family Physicians (AAFP) 2022 value-based care survey said they are participating in some form of value-based payment, and 18% are developing the capabilities to do so.

That is welcome news to AAFP President Sterling N. Ransone, Jr., M.D., FAAFP. “Our system is set up to prioritize and reimburse based on volume of patient visits versus outcomes,” Ransone says. “Value-based care prioritizes outcomes. And however we can get our population healthier is where the health care expenditure should go instead of the transactional fee-for-service environment we’ve been in for so long.”


Much of the energy behind the search for alternatives to FFS comes from the federal government through the Medicare Shared Savings Program and the Centers for Medicare & Medicaid Innovation Center (CMMI). The latter — established in 2010 as part of the Affordable Care Act, former President Barack Obama’s health care law — is tasked with developing and testing payment models aimed at improving care quality for Medicare and Medicaid beneficiaries while slowing cost growth in both programs.

The COVID-19 pandemic has also changed some practices’ thinking about the importance of participating in value-based payment programs, says Corinne Lewis, M.S.W., program officer for delivery system reform at The Commonwealth Fund.

“Fee-for-service is a volume-driven payment system, so when patient volumes dropped (in the early phase of the pandemic), especially for elective and primary care, payments decreased substantially.” Lewis says. “So, providers are recognizing the need tomove toward more value-based approaches for more flexibility and protection against future volume shocks.”

In recent years the search for workable alternatives to FFS has been fueled by growing recognition of the role that factors such as access to adequate housing and nutritious food — social determinants of health — play in determining patient outcomes.

“How can we address patients’ behavioral and social needs in order to meaningfully bend the health care cost curve?” Lewis asks. “There’s growing recognition that value-based care will be essential to all those things and that’s where a lot of the interest is coming from at the Medicare/Medicaid level as well as commercial payers and providers themselves.”

Do these developments mean value-based payment models are the wave of the future, and FFS medicine will disappear? Probably not, experts say. There are still numerous obstacles to increasing provider participation in value-based models, and powerful forces working to preserve FFS.

Among the obstacles is the term “value-based care,” says Suzanne Delbanco, Ph.D., Catalyst for Payment Reform’s executive director. “It implies that whatever care is provided is of good value, which isn’t always the case,” Delbanco notes. Instead, she says, we should think in terms of payment reform and care delivery reform, with the latter being defined as “approaching care more broadly than just one visit at a time.”

“Both are needed for either to succeed,” Delbanco argues. “Payment reform for its own sake isn’t exciting, but if it can lead to higher quality, more affordable care it becomes interesting. And new care delivery models aren’t likely to be sustainable unless there’s a way of paying for them that makes them attractive to providers and leads to better results.”

Judged by those standards, movement away from FFS is less impressive than it first appears. Although LAN’s data show 60% of 2020 health care spending was in some form of alternative payment models, most of that was in programs built on FFS but including opportunities for additional revenue such as care coordination fees or through shared-savings programs. Only 6% of total spending was population based, such as per-member per-month or global budgets, and not linked to FFS.

‘Incentives haven’t really changed’

“Fee-for-service is still at the base of most alternative payment models,” says Delbanco. “The doctor or hospital is still billing and getting paid that way. So, for the front-line physician the day-to-day incentives haven’t really changed.”

Little of this comes as a surprise to Robert Berenson, M.D., a fellow at the Urban Institute’s Health Policy Center and former vice chair of the Medicare Payment Advisory Commission. “In my view, the people who come up with value-based plans don’t really understand the strengths and weaknesses of the various models, so they just focus on what they think are elegant new incentives without realizing some of them can’t be implemented.”

He cites the example of Medicare’s implementation of a payment code for “check-in” telephone calls with patients before an office visit, under the premise that such calls might head off unnecessary visits and save the program money.

The problem, Berenson says, is that the code’s payment amount—$14.53—was less than what it cost practices to bill for the service when administrative costs were factored in. “Docs aren’t completely stupid. They aren’t going to work below costs,” he said. “It’s an example of what sounds like a good idea in theory but operationally it makes no sense.”

Another hurdle many practices—especially small ones—face with value-based payment contracts is the upfront cost of the technology and personnel they need to compile, analyze and report data showing they have met a payer’s quality metrics. Such is the case for Melissa Lucarelli, M.D., FAAFP, owner of a family practice in rural Randolph, Wisconsin, and member of the 

“Our margins are so thin right now that it’s hard for me to pay upfront to jump on board a payer’s (value-based) initiative that will increase my administrative burden and may or may not increase my revenues,” Lucarelli says.

Nearly all Lucarelli’s Medicare patients are in some form of FFS-based quality program that includes bonuses for meeting certain Healthcare Effectiveness Data and Information Set quality guidelines, she says. Whenever possible, she bills for services such as chronic care and transition care management, advance care planning and cognitive impairment assessments.

“These piecemeal things are how we’re staying afloat right now,” she says. “But the administrative burden even from these on my little independent practice is phenomenal. It’s like being in a game where they change the rules every year.”

Making the challenge even greater is the sheer number of value-based arrangements. In addition to those available through Medicare and Medicaid, virtually every commercial payer has them, each with its own reporting requirements and quality metrics. For practices in contracts with multiple payers, keeping track of it all can seem like an insurmountable hurdle.

“A lot of our members, especially in small and solo practices, say they don’t have the resources to make sure they’re following the participation requirements (for alternative payment models), or even find out what they all are,” says AAFP’s Ransone. “So, they just throw up their hands and say, ‘Forget it, I’m not even going to bother.’ ”

Ransone adds that the academy has a project underway to address the problem. Dubbed “Vision 2025,” its goal is to reduce variability in payment structure and participation requirements for value-based models so small practices can receive the enhanced payments they often provide.

CMMI, in its 2021 “Innovation Center Strategy Refresh” white paper, acknowledged these and other problems with the value-based care models it has developed and experimented with for Medicare and Medicaid. Among the challenges it cites are complexity and overlap among many of the models; difficulty for providers to join or stay in value-based plans due to administrative burden and upfront investments; and developing better coordination among stakeholders.

“Alignment with private payers, purchasers and states is needed to increase the number of providers participating in value-based payment models and to make their participation sustainable across payers,” the paper says. To accomplish this, CMMI promises more public outreach in the form of listening sessions with payers, providers and health care purchasers, as well as learning from nonparticipants about barriers they face to participating in value-based models.

The paper notes that although CMMI has launched more than 50 models during the past 10 years, only four have met its requirements for being continued and expanded. “I think a lesson from the last decade that CMMI has taken to heart is the need to focus on a smaller number of strategic models that can really move the system,” says Mark McClellan, M.D., Ph.D., professor of medicine and business at the Margolis Center for Health Policy at Duke University and a former CMSadministrator.

Another obstacle to widespread use of value-based care and payment models, experts say, is the number — and power — of individuals and institutions who are satisfied with the current system. “There are many stakeholders who are fat and happy with the status quo,” says Catalyst for Payment Reform’s Delbanco. “Too many providers, and even payers, have found ways to be profitable with payment systems and delivery models that aren’t linked to quality.”

Berenson notes that more widespread use of payment models such as capitation or bundled payments would benefit primary care physicians more than specialists, because many services the former perform are underpaid or not billable. “Many of them (specialists) earn more than twice as much as primary care doctors, and they have enough power to prevent CMS from changing that on its own or from Congress authorizing CMS to do it,” he says.

What lies ahead for value-based care and the payment models that support it? Experts believe participation will continue to grow, but that FFS is not going away — in part because it remains well suited to some forms of care. “I don’t think fee-for-service will ever be eliminated entirely, because in some cases it can be an appropriate mechanism for incentivizing care that we want to see more of,” says Lewis.

Berenson agrees, citing vaccinations as an example. Practices need to be reimbursed for purchasing the vaccines, which is next to impossible under a capitation model given their year-to-year price variation. Beyond that, Berenson says, “if you pay fee-for-service for immunizations it’s much more likely they will be performed. And when you’re using fee-for-service to make sure an important service is provided, it means you’re improving value.”

FFS is also appropriate in primary care for discrete services such as hospital visits or minor surgeries, Berenson says. But in general, he adds, primary care clinicians would fare better under some form of value-based model such as capitation.

He cites research showing that up to 30% of activities primary care doctors perform, such as calls to pharmacies or patient callbacks, are not coded and so are not billable under FFS. “The beauty of capitation is, you don’t have to code for all those services. Instead, the payer says, ‘We’re going to pay youfor taking care of this population of patients and you allocate your time and resources to accomplish that,’” Berenson says.

Duke’s McClellan says the increase in telehealth visits resulting from the COVID-19 pandemic is another reason why primary care clinicians and their payers should favor alternatives to FFS. Under FFS, he says, there is little incentive to use telehealth for the patients who would benefit the most — such as those in rural areas — and to coordinate telehealth with other community-based services those patients often need to address their health issues.

“You rarely see significant programs to address the social (determinants) of poor health in an FFS model because there just isn’t any way to do that,” he says. “How are you going to pay for air conditioners or transportation or whatever else the patient needs? Community-based health services are easier to provide widely in value-based arrangements because they’re built on the foundation of accountability for total costs and outcomes for patients.”

Ultimately, experts say, what’s needed are payment models that combine elements of FFS and value-based arrangements. For Lucarelli, such a hybrid approach would include “some form of per-patient reimbursement, or income floor, that covers stuff like doing their prior (authorizations) and coordinating with specialists.” Such an arrangement, she explains, “would allow us to provide these services regardless of the ebb and flow of patient volume during the year.”

Specific procedures, such as minor surgeries or IUD implants, should remain under FFS, she adds. “That way I’m fully reimbursed and can practice to my full scope of training. If I’m just getting a capitated amount, then doing most procedures becomes money out of my pocket and I might as well send the patient to a specialist.”

Outcomes-based models are spreading, but fee-for-service still dominates payment landscape.

Value-based care catching up to fee-for-service

Chad Wege is Vice President of Product at SyTrue.

Payers have traditionally relied on post-payment claims reviews to detect, prevent and correct fraud, waste and abuse, accurately facilitate claim payments and reimbursement, and ensure medical necessity of services delivered.

However, the post-payment review process can be lengthy, cumbersome, administratively inefficient, and result in provider abrasion. To overcome the drawbacks associated with post-payment reviews, payers have recently started implementing prepayment claim review programs that allow for prospective claim reviews, in which payers evaluate claims prior to rendering payment to providers.

While prepayment reviews are likely to provide greater savings, faster turnaround times and reduce provider abrasion, performing these audits accurately, consistently, and efficiently requires the utilization of technology that surfaces key information from patient records, enabling payers to determine the medical necessity of services that a patient received.

To this end, clinical natural language processing (NLP) technology has proven particularly valuable in enabling payers to read, extract, and produce clean information from unstructured data buried in the narrative sections of patient records. NLP organizes disparate, unstructured data into a comprehensive, longitudinal, and semantically interoperable patient record that captures all key health information, such as diagnoses, treatments, and care plans.

In addition, accurate claims routing and workflow plays an important role in increasing efficiency of claim reviews in a pre-pay environment. This includes document management, ensuring all pertinent information is present for a determination to be made, and a rules-driven dispatch to ensure claims are routed to an appropriately skilled auditor to optimize productivity.


For some payers, the “pay-and-chase” post-payment review process has become deeply ingrained over many years. The process involves reviewing claims after payment, verifying whether the services described in those claims are medically justified for a given patient’s diagnosis, and then attempting to recover funds when overpayment has been identified.

This retrospective form of analysis requires a significant investment in resources for post-payment reviews and overpayment recovery efforts. In addition to the resources required to retrieve documentation from often disparate sources in a timely manner, the “pay-and-chase” process increases provider abrasion by retracting portions of prior payments which results in additional administrative overhead, detracting resources that are otherwise focused on patient care.

While post-payment reviews can negatively impact payer-provider relationships, the industry has found that “pre-submission notification,” a process in which payers alert providers of potential errors before the claim is submitted for payment, can result in goodwill from providers. By enabling providers to file more accurate claims, pre-submission notification helps reduce administrative burdens and lower costs, greatly reducing the negative experiences of providers.

Separately, Medicare administrators have experienced success in moving away from a “pay-and-chase” approach to one that involves more upfront education and technology to predict improper payments. The U.S. Centers for Medicare and Medicaid Services (CMS) in 2021 

 its lowest-ever improper payment rate of 6.26%, a substantial improvement from 2014 when the figure stood at 14%.


In the past, payers have depended on costly and time-consuming chart reviews to find and extract key unstructured data from patient records and claims. In recent years, however, NLP has played an increasingly important part in confirming payment integrity prior to payment.

By giving computers the ability to read, understand, and interpret clinical language, NLP extracts and organizes data from patients’ episodic health records, enabling payers to modernize chart review processes and eliminate antiquated and bloated workflows associated with manually reading a medical record. Leveraging NLP technology in audit workflow tools unlocks the key pieces of data buried in unstructured documents to empower more accurate automation of claims management. Organizing and presenting claim-specific data elements to auditors provides a rapid and efficient path to determination.

A significant advantage of NLP is that chart reviews can be performed just one time to extract all key patient data, as opposed to multiple reviews by multiple clinicians, researchers, or auditors who are all looking for different pieces of information. Further, NLP technology is a key component of interoperability between healthcare information systems, structuring and standardizing health information from a wide variety of sources including claims and patient charts.

In cases when payment integrity is in question, there is often a pattern of repeatability in the data, such as a large number of patients meeting the same prior authorization requirements. NLP helps payers detect these patterns that lack the natural variability found in legitimate patient records before claims are paid.

In the same respect, NLP can help payers spot unusual data that may be representative of fraud, such as expensive tests for which there is no medical necessity. With its ability to accurately analyze unstructured data to identify anomalies within records, NLP can quickly verify the presence, or lack of, substantiating data.

Post-payment claims reviews are a backward-looking process that should largely be confined to the healthcare industry’s past. In contrast, with prepayment reviews that leverage NLP to surface new insights from unstructured patient data, payers can improve the speed and accuracy of claims adjudication while cutting administrative costs. This ultimately improves a payer’s cash flow by saving millions of dollars from leaving the organization in the first place.

The post-payment review process can be lengthy, cumbersome, administratively inefficient, and result in provider abrasion.

Using natural language processing to improve prepayment reviews

Many primary care physicians might say they are. After all, they have spent years building relationships with patients, sometimes treating multiple generations of the same family and learning as much about their private life as their medical history during office visits. Who better to give a diagnosis than someone who knows not only the patient’s ailments but where and how they live, and what nonmedical factors might be affecting their overall health?

But other primary care doctors know this nostalgic view of patient care is heading the way of house calls and the little black bag. Gone are leisurely discussions with patients aimed at pinpointing root causes of health issues. Now, there are corporate RVU goals, patient quotas and productivity spreadsheets. Time for patients is spent instead with electronic health record screens, administrative paperwork and computer systems that often cannot communicate across departments, let alone across the street.

To make matters worse, there simply are not enough primary care physicians. The American Association of Medical Colleges predicts a primary care shortage of between 17,800 and 48,000 doctors by 2034, and those estimates were made before COVID-19 drove some doctors into early retirement or other professions (40% of physicians reported feeling burned out before the pandemic). In addition, by 2034, the U.S. population is expected to increase by 10.6% with a projected 42.4% increase in those 65 or older — the people most likely to need care. More than 2 in 5 physicians will be 65 or older in the next decade, further thinning the doctor ranks.

America already trails most countries in doctors per capita. As of 2019, the U.S. average was 2.64 doctors per 1,000 citizens compared with the global average of 3.37 — an improvement from 1993 when the U.S. number was 2.4.

The result, predictably, is that the patient loses. Monthlong waits to see a primary care physician, rushed appointments, increasing costs taking money out of patient paychecks, and rising copays add up to frustration with the health care system.

Patients want a quick appointment to find out whether their case of the sniffles is anything to worry about; they do not want to be told they cannot see a doctor soon because they are caught up in the macroeconomics of the country’s inefficient health care system.

So, what happens? The patient takes charge. “Patient” is just a medical term for “consumer,” and today’s consumer does not want to wait.

“There’s a big focus on convenient care,” says Tom Florence, president, permanent physician placement, AMN Healthcare/Merritt Hawkins, a health care search firm. “A lot of patients, particularly younger patients, don’t want to wait around in the physician’s office, so fewer younger adult patients even have a regular family practice doctor. They want everything now.”

This demand is driving retailers like CVS and Walmart to get into the primary care game by opening clinics. The consumer wants medical care without a wait, and big corporations and private equity see an opportunity. Inevitably, someone will fill the gaps created by the shortage of primary care physicians.

So, who is in charge of primary care? The consumer, and that has led to a surge of nonphysicians willing to provide such care, often with little or no supervision from doctors thanks to increasing public pressure on legislatures to act.

In 2004 there were 106,000 nurse practitioners (NPs). Today there are 355,000, a growth rate of 235%. For physician assistants (PAs), in 2010 there were 89,019. Today there are 159,000, a growth rate of 79%.

With a shortage of primary care physicians leaving more than 90 million people without access to primary care, according to the Health Resources & Services Administration, it is not surprising that NPs and PAs are filling the gap and being sought to do so.

Retailer clinics are trying to provide more primary care access, but Florence says, “They’re doing a lot of that work through nurse practitioners or PAs.”

The same is often true for urgent care clinics. One startup, Mitesco, which owns The Good Clinic chain in Minnesota and looking to expand nationally, is staffed only by NPs — something it touts in news releases, saying they allow “equal care while cutting costs 25%.”

Mitesco is not alone. Florence says professional searches last year for NPs and PAs slightly exceeded those for primary care doctors for the first time, and searches for NPs were higher than for any other position. “Retail clinics, urgent care, a lot of telehealth are starting to trend toward specifically looking for advanced practice care candidates,” he says. “That’s more about the dollars and cents of it, meaning if we (the urgent care) hire a staff member who costs less, then our expenses are less costly, (and) then this becomes a more profitable venture for whoever is doing the hiring there.”

Despite increased demand for NPs and PAs, Florence says primary care physicians need not worry about a lack of job opportunities. “Family medicine was our No. 1 search for 14 years in a row up until last year; now it’s No. 2,” he says. “I do see a trend where the convenient care lens is a little more tilted toward an advanced practice candidate, whereas hospitals and health systems, generally speaking, prefer to have a physician in place and utilize advanced practice to help.”

The surge in NPs and PAs should not be surprising; both professions were founded as a means of providing more primary care. The first class of PAs graduated in 1967, with all four members having been Navy hospital corpsmen who had considerable medical training during their military service, according to the the American Academy of Physician Associates (AAPA). The PA concept gained federal acceptance and backing as early as 1970 as a creative solution to the physician shortage.

“PAs have been practicing primary care for over 50 years,” says Jennifer M. Orozco, PA-C, president of the AAPA. “I think where PAs fit in is they are often a patient’s primary care provider, just as physicians are, just as sometimes NPs are. Even with all that, we still have more than 95 million patients in the U.S. (who) lack access to primary care … and we have this growing need of chronic health conditions that need to be addressed, from diabetes to obesity. There’s no plethora of problems that are going to go away.”

NPs got their start in the late 1960s because more primary care services were needed for underserved populations. “NPs bring a comprehensive perspective to primary care,” says April N. Kapu, D.N.P., president of the American Association of Nurse Practitioners (AANP). “NPs assess patients, order and interpret diagnostic tests, make diagnoses and initiate and manage treatment plans, including prescribing medications. Today, 82% of adults report they’ve been treated or know someone who has been treated by an NP, and a vast majority of health consumers — nine out of 10 patients — support policies and legislation that remove barriers to NP practice and strengthen patient choice in the selection of a health care provider.”

Although there is some specialization among NPs, almost 89% choose primary care as their area of focus.

As their members’ roles have expanded, the AAPA and AANP have worked to shape their public image as more independent professionals and not just someone on a doctor’s staff. For example, in 2008, AANP petitioned pharmaceutical and health care product companies to use provider-neutral language in consumer print and broadcast advertisements. It has also invested in public relations efforts to change public perception of an NP’s role in the health care system. In late 2020, the AAPA voted to officially change the professional title to “physician associate” rather than “physician assistant” to better convey a PA’s ability to manage patients’ care autonomously.

NPs have full practice authority — meaning they do not require a supervising physician and can see patients on their own — in 26 states, whereas physician associates have full practice authority in just three states, even though their clinical requirements exceed those of NPs.

To become an NP, the person must have a bachelor’s degree in nursing, be a registered nurse, graduate from a master’s program with either a Master of Science in Nursing or a Doctor of Nursing Practice degree, and then pass the National NP Board Certification Exam. The graduate can then apply for state licensure. Most licenses must be renewed every two years, typically with continuing medical education credits of between 20 and 30 hours required annually, depending on the state. National certification by the AANP lasts five years.

Nurse practitioners and physician assistants keep taking on more primary care responsibilities, often without supervision of a doctor