VBC Industry Insights From HCP-LAN’s Annual Report

Values-based healthcare reimbursement has been adopted more quickly in some healthcare sectors than in others.


According to the LAN’s latest APM Measurement report, 40.9% of US healthcare payments—representing over 238 million Americans and more than 80% of the covered population—were generated through value-based reimbursement programs last year. Population-based payments and downside risk agreements were included in these programs, in addition to upside risk agreements.


In addition, almost one fifth (19.8%) of all healthcare payments made last year were in some way tied to value or quality of care while still being based in fee-for-service. The remaining 39.3% of payments were strictly fee-for-service.


Despite the fact that the healthcare industry has adopted value-based reimbursement, adoption is often glacially slow. But values-based reimbursement has been adopted quicker in some segments of the healthcare system.


Where progress is occurring.

According to the APM Measurement report, Medicare and Medicare Advantage are leading the charge in value-based reimbursement – no surprise there.


Just 15.0% of traditional Medicare payments and 38.0% of Medicare Advantage payments were fee-for-service in 2020, down from 2019 data showing 14.1% of traditional Medicare payments and 46.0% of Medicare Advantage payments being fee-for-service.


In both programs, the proportion of value-based reimbursement in two-sided risk alternative payment models continue to increase year over year. In traditional Medicare, 24.2% of payments were part of some two-sided risk model, compared to 20.2% in 2019. In Medicare Advantage, the percentage of payments in two-sided risk models increased from 28.6% in 2019 to 29.3% in 2020.


Insight: Medicare Full Risk grew by 20% between 2019 and 2020.

Medicare Advantage Full Risk grew only 3% in the same period.


Despite fee-for-service payments making up 59.0% of Medicaid payments in 2019, value-based reimbursement adoption increased from 10.6% to 14.5% in 2020.


Insight: Value-Based Reimbursement adoption grew 36% 2019-2020


According to the report, private payers covered 62% of the lives represented in the LAN’s data, but only 10.8% of payments made in 2020 were from two-sided risk models, while over half (51.5%) were from fee-for-service.


In addition, a higher proportion of payments to providers from private payers (11.1%) in 2019 was tied to two-sided risk models. Furthermore, 53.5% of payments were fee-for-service, as shown in the report.



How to accelerate value-based payment and risk

Industry experts at the 2021 LAN Summit concur that a lag in value-based reimbursement adoption is shown by the results of the 2020 APM Measurement report. However, there is speculation that risk-based models will be adopted more rapidly over the next few years.


According to the report, 87% of respondents believe that alternative payment model activity will increase; none of them believe it will decrease. In addition, the majority agreed that adoption would lead to higher quality, more accessible care, as well as improved care coordination.


Despite the payors’ perspectives, provider willingness to take financial liability, their capability to implement models, and their interest and willingness are still the greatest barriers to value-based payment adoption.


An “exponential” increase in the level of cooperation between payers and providers has occurred, and more providers are bringing to us the idea of entering into risk arrangements, Shrank said. Because of the outbreak, he thinks more people will be open to working in risk arrangements.


However, payers still must offer the right incentives to incentivize providers to participate in value-based reimbursement and eventual downside risk.


Keeping the momentum going with value-based reimbursement and risk adoption in healthcare requires leadership, buy-in, and aligned incentives.


How Hospitals Can Tackle Surges With Value-Based Care

With the flu season ramping at unprecedented rates, and a new surge of RSV coming when COVID-19 numbers are rising again, the topic of a healthcare surge emergency is back in the headlines. What the New York Times is calling a “Tripledemic” is threatening to overwhelm providers and hospitals yet again. During the peak of the pandemic, hospitals experienced a surge in demand for physical resources and personnel that lasted nearly two years.  And just when things started to adjust back to some recognizable norms, the question is again on everyone’s mind: “How do we tackle a surge?”


According to Shereef Elnahal, MD, president and CEO of University Hospital and former Commissioner of New Jersey’s Department of Health, hospitals and health systems often lose money during their peak seasons. Supply shortages are largely due to the fact that most hospitals use a fee-for-service payment model.


Hospitals that charge on a fee-for-service basis are paid based on the volume of patients they treat, not the quality of patient outcomes. Because of this, hospitals usually operate at full capacity in order to reap the greatest rewards. When patient volumes rise during peak seasons, however, hospitals have little margin for error.


According to static payment rates for inpatient care, hospitals may struggle with seasonal demand. In order to keep up with surges, health systems may have to hire more staff or order more supplies, which leads to increased expenses despite no increase in revenue.


During flu season, primary care physicians often augment their workforce by up to 30 percent and still face financial challenges and capacity limitations. Across all healthcare facilities, staffing shortages have become worse as a result of the COVID-19 pandemic, which increased the need for healthcare professionals.


Rather than relying on simply adding more headcount, health systems needa model that can easily adjust healthcare delivery to fit any situation, including increased patient capacity and pandemic surges. Creating a value-based payment model may give health systems more flexibility when dealing with demand surges.


According to the quality of care, providers are compensated using value-based payment models, not the quantity. This approach may inspire health systems to improve staffing procedures. In contrast to dividing physicians’ time in a way that will lead to the highest number of completed services, health systems might focus on patient needs and health outcomes in order to address them.


Physicians using a value-based model are less likely to refer patients to specialty care facilities if those referrals are not medically beneficial.

Because of Maryland’s value-based all-payer model, which reimburses hospitals using global budgets for inpatient episodes of care, hospitals in the state were able to manage the influx of patients during the pandemic far better than neighboring states with different models.


A study from JAMA Network Open noted that the all-payer model also decreased surgical spending and surgical complications. Providers can save resources and supplies for busy periods if they are reimbursed based on outcomes rather than quantity of services.


Patients may be able to avoid expensive hospital stays, saving staff time and resources, if they have access to healthcare services at home. Hospitalization rates may also be lowered by using home-based primary care services.


In addition, health systems could leverage telehealth services to assess patients and determine if an in-person visit is required. According to the authors, telehealth use could improve access to care and save hospitals money.


Patients may also be able to manage their acute conditions from home using remote patient monitoring technology.


Surges can also be a contributing factor to physician burnout. That is why reducing physician workload (blog post) should be a part of hospitals’ strategy of dealing with patient surges.


The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.


After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.


What methods does the app use to accomplish this?


Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!

HCC Codes Most Targeted by DOJ and Strategies to Remain Compliant

Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever. 


The DOJ sued Cigna in October, the Supreme Court refused to intervene on behalf of Molina Healthcare’s whistle-blower case, and more negative audit and antitrust cases are appearing daily.. You may be  doing your best but that is no defence in an audit. The only things that matter are facts, documentation, accuracy, and pure compliance. Practicing medicine is an art, but documenting is a strict science, and anything less than precise documentation may result in poor audit outcomes and your company’s name up next in the headlines.


The DOJ is relentless, but not unpredictable. It turns out, they consistently target the same set of codes in nearly every suit. Apparently, the “low-hanging fruit” can be bucketed into four simple categories: Acute coded as chronic; Lack of clinical accuracy or supporting documentation (MEAT Criteria); and Diagnosing without changing the plan of care. 


We’ve pulled together a list of “The Usual Suspects” – HCC codes that appear most frequently in DOJ audits, and married the specific codes with strategies to both find them in your EMR and avoid them in your coding. Access the most common offenders in our free report.


Download the FREE REPORT


HCC Codes Most Targeted by DOJ and Strategies to Remain Compliant.


Learn How To

  • Identify codes most commonly identified in DOJ audits
  • Implement three best-demonstrated practices to improve compliance
  • Discover resources and tools to improve compliance and harden against negative audit outcomes



What Is HCC Coding?

Back in 2004, CMS introduced HCC coding as a tool to help estimate Medicare costs. Today, HCC coding us used across Medicare Advantage plans, the Medicare Shared Savings Program, Medicaid, and private health plans – all deploying a variation of the risk adjustment model in order to quantify the upcoming cost of care for their member population, and as a mechanism of submitting that care need to CMS for payment. And yet, the question comes up more often than you may think: “What is HCC Coding?”


Even in the value-based care space, there is confusion around HCC coding, which ICD10 codes risk adjust, and how to diagnose and document accurately and specifically. So if you’re moving from fee-for-service into VBC, taking on risk for the first time, or a veteran at HCC coding for VBC, this article will clarify much of the confusion and simplify what HCC coding is, why it matters, how it is used and what the future holds for HCC and VBC.


Do Doctors Know HCC Coding?

First, clinicians typically have a good working knowledge of ICD-10 codes. And every org has their lookup functions baked into the EMR. However, not only do most ICD-10 codes not work as HCC codes, many of the traditional ways of diagnosing in the fee-for-service world are turned on their heads in VBC. So knowing or having access to ICD-10 codes is not actually that much of an advantage when learning HCC coding. In fact, in some cases, that knowledge can be a liability. 


Knowing the code to document diabetes is great, but using that same basic E11.9 that you’re used to is not helpful when diagnosing in a risk model. You need to dig into the complications, the severity of the disease state, and both diagnose and document with high specificity in order to treat and afford to treat the full complications of the disease. If you under-diagnose, you will likely under-treat, and risk an avoidable hospitalization, the risks to the patient and the costs notwithstanding. So in the case of diabetes, a quick check of the toes could yield a missed diagnosis that is critical to the patient’s care as well as accurate RAF and adequate capitation.


What are HCC Codes?

Hierarchical Condition Categories – as the name implies, the categories relate to a hierarchy of of conditions, and it all works together as an efficient sort function to calculate the risk that the patient’s will be expensive. Think about it like this: A patient with mild diabetes as unlikely to end up in the ER due to their disease, so basic diabetes does not risk adjust; whereas a patient with severe diabetes with complex circulatory symptoms that have already led to amputation of one toe is at extremely high risk of ending up in the ER, and they will require a lot of personal and intense care to keep them out of the hospital. And care costs money, so risk and care are nearly synonymous. A higher risk diagnosis gets an HCC code with a higher risk adjustment score, which adds a higher multiplier to the capitation of that patient – meaning the government pays more dollars a month to maintain that disease and help that patient stay out of the hospital.


How do clinicians use HCC coding? 

The primary use of HCC codes is to document new chronic condition diagnoses, and recapture chronic conditions being treated, and communicate those diagnoses to Payors and CMS in order to receive capitated payments.


How do HCC codes translate to revenue?

The payment model is obviously vastly different from the traditional fee-for-service (FFS) format where actions are performed, justified, transmitted as CPC codes and reimbursed by payors and/or CMS. In the VBC model, a patient is diagnosed with a specific chronic condition, that condition is documented and coded based on hierarchical condition categories that adjust the risk associated with keeping that patient healthy and out of the hospital. By taking on that risk, the plan or provider group is agreeing that, if given a reasonable amount of money, they will be able to maintain the health of that patient. That money directly ties back to the HCC codes documented, and is paid on a capitated model, with a certain dollar amount paid per-member per-month (PMPM). Those payments allow the overall organization to provide excellent care to the entire patient population, paying extra attention to those whose disease states have reached a complexity where significant resources are required to maintain optimal health. Whether for-profit or non-profit, the organization providing care will financially benefit from accurate diagnosis coding and aggressively proactive care. 


How does HCC coding help doctors get paid?

When done correctly, practicing medicine in a Value-Based Care arrangement means more time for doctors, less administrative burden, less burnout and more time to spend per-patient. Smaller panels, and more help treating patients mean that a good doctor can provide truly life-changing care to patients without over-working or over-coding. And by practicing good medicine with proper HCC documentation, you will find your organization flourishing and your patient outcomes improving – all while actually decreasing the overall cost of healthcare. Sure, there is no such thing as a perfect system, but this is as close as we can get in today’s environment. And with an eye to continuous improvement, good coding and good care puts your organization squarely on the path.


How does HCC coding translate to patient care?

You cannot treat what you do not diagnose. And if you diagnose with an eye to changing the trajectory of the patient’s care plan, you are practicing good medicine. To diagnose without proper documentation denies the patient the care that comes from critical revenue. And to document without care is, simply put, fraud. So diagnose with high specificity and proper documentation to ensure that your clinic can afford to provide the kind and quantity of care that will keep your VBC patients out of the hospital. Better HCC coding = better care.


How long does it take to learn HCC coding?

Depending on the tools used for teaching and learning, it can be a years-long process fraught with frustration and difficulty – OR – it can be a simple weekly check-in on an app that uses modern learning methodologies to make mastery quick and easy.



How does HCC coding relate to compliance audits?

The number of compliance audits of provider groups has been steadily rising. The DOJ launches new lawsuits against both large payors and smaller provider groups with increasing penalties. And the Supreme Court has refused to step in and ease the pressure, letting whistle-blower cases proceed unchecked. Clinicians are doing their best, but that is no defense in an audit – the only thing that matters is facts, documentation, accuracy and pure compliance.  


Practicing healthcare is an art, but documenting is a strict science, and anything less than accurate documentation vigorously maintained will likely result in negative audit outcomes and your group’s name landing in next month’s headlines.


CMS and DOJ have been increasingly scrutinizing payor strategies and billing patterns as it pertains to Hierarchical Condition Categories (HCCs). As more and more physician groups take on risk in the VBC models, it is imperative that physician groups do not make the same mistakes as their payor partners (intentionally or not). 


Some of the most common offenses are fairly simple to avoid. But as we all know, simple does not mean easy. In fact, achieving simplicity can be far more difficult than creating complexity – which is what happens most of the time. A simple solution requires tremendous discipline. 


HCC coding for acute conditions

As a rule of thumb, an acute code should not repeat 2 years in a row for a specific patient. And usually, even the first year is inaccurate. Acute heart attack is one of the most common errors penalized by CMS and the DOJ. One reason for this is misunderstanding how to document “history of heart attack” vs “heart attack.” Another version is chronic conditions that have been mis-coded as acute. There is a very short distance between upcoding and practicing good medicine. 


It is sometimes appropriate to use these within the year where the acute event occurred, but the following year you must diagnose and document a different code. A third of the most common acute condition dinged by CMS is the combination of #1 & #2 – Acute Stroke and Acute Heart Attack. 


Lack of clinical accuracy or supporting documentation – Medical diagnoses are complex and sometimes exist in the gray area between possibilities – but coding and compliance are hard rules. Picking the wrong code. Commonly misused diagnoses. While RADV audits are routinely looking for MEAT criteria, they’re not looking for clinical criteria or diagnostic accuracy. 


Commonly misrepresented diagnoses: The exact criteria can be confusing even though the treatment can be the same for mild, moderate, and severe forms of certain diseases. Misrepresentation of the severity can result in overpayment from CMS, and legal and financial penalties – not to mention the obvious ethical concerns. 


What is HCC Coding Without Plan of Care?

Now that a doctor has diagnosed a chronic condition, what is the plan to treat or manage the disease? A diagnosis that does not demonstrate a direct and deliberate impact on the plan of care is almost always incorrect at best, and in an audit, illegal. Diagnosing and documenting should function as a mechanism of providing care; documenting to document is never correct. So be on the lookout for conditions diagnosed and codes submitted that do not impact the plan of care. These are often targeted by CMS, both in OIG compliance audits and RADV audits.


How is HCC Coding improved by Education and 1-on-1 coaching?

Build a culture that connects patient care to diagnostic specificity and accuracy in coding and documentation. No doctor wants the business managers coming down from their offices, clipboard in hand, scolding about how code capture and RAF scores impact revenue. But every clinician understands the need to improve care and decrease cost. So start there – in VBC, practicing good medicine and providing better care starts at accurate diagnosis right through to rigorous documentation. 


Documentation enables treatment, funds resources to provide care, ensures better health outcomes for patients and actually lessens clinician workload – when done correctly. Chart audits do not have to be brutal, they can be helpful, asking clinicians how a particular diagnosis changes the care trajectory, and helping document for maximum patient benefit. Internal meetings should focus on coding as care. And manual chart reviews should be performed by medical doctors to give timely 1-to-1 feedback. If this is done, the last error on the OIG’s list of usual suspects will go down:


How does HCC coding impact clinician workload? 

It can go either way – with increased coding requirements becoming a burden, both to learn in boring seminars and to chase down in chart reviews. But with modern advanced app-based learning tools like DoctusTech, clinicians can master HCC coding in as little time as 5 minutes per week. 


What is HCC coding to the OIG?

The Office of Inspector General of the Department of Health and Human Services is at the forefront of auditing healthcare fraud, and recommending action from the DOJ. 


From OIG: Since its 1976 establishment, the Office of Inspector General (OIG) has been at the forefront of the Nation’s efforts to fight waste, fraud and abuse and to improving the efficiency of Medicare, Medicaid and more than 100 other Department of Health & Human Services (HHS) programs.


In today’s healthcare landscape, the OIG is finding value-based care to be a target-rich environment, with special focus placed on Medicare Advantage programs, as these allow a small action (documenting a chronic condition that does not actually exist) to multiply into a year of capitated payments to an organization. The simple act of up-coding a condition into something more complex than it should be or over-coding by documenting a chronic condition that does not exist results in thousands of dollars per year in fraudulent overpayments. 


What is HCC coding to the DOJ?

While the Department of Justice is not directly concerned with healthcare, they are very concerned about medical fraud, which defrauds the government’s medicare programs, and in extension, the American people. Most often, the DOJ takes on whistleblower cases, where an individual from inside an organization shares insider information regarding acts of upcoding or overcoding that are both large and systemic. These whistleblowers stand to profit significant sums, at times earning up to 20% of the total settlement. And with the recent Sutter case settling at $90,000,000, the whistleblower could potentially take home $18 Million. The False Claims Act ensures that the federal government has a means of penalizing organizations and individuals who, through filing false claims, defraud the government. While this law has been in place since the 1800s, it is getting renewed attention as the DOJ discovers millions of dollars in false claims specifically in Medicare Advantage programs, as these allow an organization to bill CMS with very little scrutiny or oversight. 


Top mis-used HCC codes

We address this in a report, feel free to request it HERE.

Also, codes most found in unlinked chart reviews, and subject to RADV audits are detailed in our white paper, found HERE.


What are the requirements for HCC coding documentation? 

Generally referred to as the MEAT Criteria, here are the four things you must have to document an chronic condition with an HCC code:

M = Monitoring by ordering or referencing labs, imaging studies or other tests

E = Evaluation with a targeted part of the physical examination specific to a certain diagnosis 

A = Assessment of the status, progression or severity of the diagnosis 

T = Treatment with medication, surgery, lifestyle modification, or referral to a specialist.


What are the best HCC coding tools?

What apps are available for learning, search, lookup, documentation? This may be a bit of a self-promoting softball, but if you haven’t checked out the DoctusTech app by now, you really should. Make time with a member of our team to see if the DT app is right for your team. Demo DoctusTech today.


What is the best way to change physician behavior around HCC coding 

Notes and insights from a study published by AJMC on how to change physician behavior. “The authors evaluated methods for implementing clinical research and guidelines, in order to change physician practice patterns, in surgical and general practice. They evaluated the effectiveness of different implementation methods.”


And as we have demonstrated through successful behavior change in physicians using our HCC coding education app, the most common solutions aren’t the most effective when it comes to ongoing positive change in physician behavior. Want to learn how to change physician behavior? Let’s dig a little deeper into a review of reviews, revealing some hard truths.


We’ve been saying for years, lectures do not work. Emails do not work. If you want to know how to change physician behavior on HCC coding, don’t take our word for it. The American Journal of Managed Care released a systematic review evaluating fourteen medical reviews in an effort to understand which interventions are most effective in changing physician behavior for the better and improving patient outcomes. 


It is evident from their publication that the methods of intervention most commonly deployed in teaching doctors HCC coding are rarely able to create lasting change in physician behavior. 


What is the best tool inside the EMR?

The DoctusTech Patient Data Analysis Platform (PDAP) is the premier tool for Value-Based Care, living inside the EMR and helping clinicians find and use the best HCC codes, track and manage care associated with chronic diagnoses, and learn which codes to use for which patients – all while reducing clinician workload. It helps readdress conditions diagnosed last year, significantly improving recapture rates. And it helps administrators see into the data by clinician, patient, clinic or by codes. Learn how the DoctusTech PDAP can help your patients and your doctors live happier, healthier lives. Demo DoctusTech today.




DOJ Files New Medicare Abuse Lawsuit Against Cigna

DOJ Audits And How DoctusTech Helps


The Department of Justice has filed a new lawsuit against Cigna for overcharging the federal government by purposefully inflating how sick its Medicare Advantage members are.


Federal prosecutors previously declined to intervene in this whistleblower case, but have now seemed to change their minds about it.


The lawsuit brings up a very important point: Medicare fraud is a widespread practice. This lawsuit has just been another push by the government to crack down on insurers who exaggerate enrollees’ conditions in order to get more money from Medicare.


Over the past 2 years, the DOJ has joined separate, similar lawsuits against Medicare Advantage plans run by Kaiser Permanente and Elevance (formerly known as Anthem) and settled cases with several other similar organizations.


The lawsuit focuses on risk adjustment

The lawsuit focuses on risk adjustment – a process in Medicare that pays insurers more if patients are sicker than average. Some patients are assigned a higher ‘risk’ score’ than others due to conditions like diabetes, heart disease, etc.


Risk adjustment is a program to encourage insurers to cover people who might be considered a higher risk, even though they might be healthy. However, the current risk adjustment program also gives incentives to insurance companies and their vendors. They may prioritize coding diagnoses and bundling them together depending on your age or other factors.


The lawsuit specifically claims Cigna abused in-home assessments, where nurses and other clinicians go into a patient’s home and conduct health screenings.


The DOJ said Cigna’s home visits were designed to generate revenue for Cigna, not to provide medical care or treatment. They cited several instances in which people were diagnosed with things like rheumatoid arthritis but never received the blood tests they needed to confirm the diagnosis.


The practice of adding more conditions without verifying their accuracy is illegal. Every year, insurers have to attest to Medicare that they are following the rules and practices set by them. The overall practice is extremely profitable for Medicare Advantage insurers – potential profits could be thousands of dollars per year for just one patient.


The lawsuit by the DoJ is a cautionary tale on why it is imperative and critical for healthcare service providers to make their doctors compliant by coding accurately, documenting everything and providing proper justification.


How DoctusTech Helps Protect Against Actions Like This

HCC Coding Education in an app: DoctusTech helps train clinicians on proper VBC diagnosis requirements in a fun and engaging app. Through clinical vignettes and gamification, doctors learn quickly and accurately how to diagnose for risk, which HCC codes to use for what, and how to meet MEAT standards on all documentation. Learn how the DoctusTech app can help keep your team compliant today.


HCC Coding Implementation In Your EMR

DoctusTech Patient Data Analytics Platform: The PDAP sits inside your EMR and provides a simple pathway to capturing unique accurate diagnosis codes, recapturing appropriate past codes, and document appropriate MEAT standards were met to ensure highest data integrity and audit preparedness. To assist admins manage recapture codes across the organization, the integrated solution provides an Admin Portal that lists the recapture rates across clinic, provider, and patient level. This ensures that you have all the necessary information at your fingertips on clinics, providers, and patients as it relates to HCC coding, documentation, accuracy, and more.

Health Systems Set Sights on Risk-Based Payment in Medicare Advantage

Nearly 60 percent of health systems are looking to move into risk-based Medicare Advantage programmes in the coming year, according to the Healthcare Financial Management Association (HFMA) executive survey for Guidehouse Health Insights. This is a 14 percent increase from the June 2019 Guidehouse/HFMA analysis, Guidehouse said.


According to the survey of over 100 CFOs and finance and managed care executives from provider organizations, Medicare Advantage isn’t the only line of business that will take on risk in 2022.


More than half of executives (52% ) plan to increase risk-based payment or capitation in their commercial lines of business, while 49% anticipate taking on more risk or capitation through Medicare alternative payment models. In other words, health systems expect risk-based payment to both increase and diversify across business lines.


More than one-third of executives believe that risk-based payments will increase in managed Medicaid, 33 percent in direct-to-employer arrangements, and 12 percent “otherwise.”


According to Guidehouse Partner Richard Bajner, we are seeing increased interest from providers to own the premium dollar through risk-based arrangements. Large payers, on the other hand, have been investing directly in primary care assets to gain control over the flow of care and better manage services delivered to members, increasing the need for payors and providers to collaborate closely on market strategies, according to the press release.


According to Guidehouse, payviders, the value-based partnership between a payers and provider, can employ risk-based contracting between payors and providers, provider-sponsored health plans, joint ventures, and payor-new-entrant partnerships to encourage the adoption of employer-sponsored health plans.


Payvider models, however, are not suitable for all markets, the study found. Furthermore, a recent survey discovered that health systems faced substantial challenges in establishing strategic partnerships with payors, a crucial element of payvider success.


According to the survey, 50% of executives cited pursuing payor models or increased risk, capitation, or joint venture arrangements as their top external challenge. This challenge was chosen over local competition (21%), legal/trust issues with payors (10%), other (9%), new entrants/disruptors (6%), and price transparency compliance (4%).


Despite the challenges with fee-for-service, risk-based revenue has stalled.


In addition, 52 percent of executives said that vertically integrated health plans, such as UnitedHealth Group, were a major barrier to success with pay-for-performance models in their market.


According to the survey, 36% of executives see data and technology costs, integrity, reporting, and insights as their greatest internal hurdle to pursuing payvider models or increasing risk, capitation, or joint venture arrangements. Internally, health systems are having trouble with data and technology.


23 percent of those surveyed cited lack of collaborative payor/provider partners as the biggest challenge to achieving quality or cost outcomes, while 13 percent said scale, 10 percent said difficulty achieving quality or cost outcomes, and 9 percent said leadership alignment or support was the most challenging aspect (Klaphake, 2018).

Despite taking a risk-based payment approach, most health systems are still developing the required capabilities in-house. Thirty percent of executives said their organisation is collaborating with a health plan, 21 percent are outsourcing capabilities, and 7 percent are sourcing capabilities from other healthcare organisations. Around half (51 percent) believe the abilities are being developed in-house.

DoctusTech Helps: Change Clinician Behaviour

According to the American Journal of Managed Care (AJMC), the least effective method for continuing medical education (CME) for clinicians is distributing printed materials: emails, PDFs, flyers, email blasts, and so on. Many medical professionals believe that clinician education should be concerned with encouraging continuous development rather than simply raising consciousness. What, then, are the most effective strategies for accomplishing the goal of both informing and changing clinician behavior?


The AJMC says that the methods of intervention most commonly deployed in teaching doctors HCC coding are those same methods determined to rarely create lasting change in physician behavior (classroom lectures, emails, PDFs, flyers, email blasts). So most frequently utilized modes of learning are clearly out.


“When you’re seeing patients, you remember the questions, and you remember what you need to ask the patients.” – Dr.  Villaplana-Canals, Florida, DoctusTech App User


Both the AJMC and common sense agree  that active education methods and multifaceted interventions are the most effective when it comes to educating and changing physician behavior. The DoctusTech mobile app provides active education and multifaceted interventions through clinical vignettes. In other words, our app helps you achieve your desired outcomes – as a physician, or as an operator for your physicians. In fact, we provide the most effective intervention methods, demonstrated by consistently better outcomes.




Learning in the app is driven by clinical vignettes, placing clinicians in a real-life patient scenario, presented with symptoms and facts, and then asked questions about diagnosis and documentation, all in an effort to alter the method of diagnosing from the fee-for-service approach most physicians were educated in to a value-based care system, in which chronic conditions are diagnosed in a very specific manner, with an eye to risk and outcomes. By including any and all information about the diagnosis that impacts risk adjustment in the diagnosis, clinicians learn to both diagnose and document those diagnoses with supporting information in the chart.


“The mobile app is wonderful, in that it’s a clinical vignette – it’s what is literally in front of their face, and it gets them thinking.” – Teresa, Director of Clinical Documentation Improvement


For clinicians, behavior change is accomplished through learning in clinical vignettes with the DoctusTech mobile app. Doctors learn more deeply and permanently about diagnostic procedures and proper documentation by sitting through a clinical vignette. The socratic method is a highly regarded teaching tool as well as being one of the most commonly used teaching strategies in medical school. The socratic approach is utilised by medical students as they learn by questioning in clinical vignettes. It is fitting, therefore, that they will gain a new store of knowledge through clinical vignettes.


“It does reinforce for us something that, although most doctors use a problem list, most of the problem lists … ended up being too long, too nonspecific, and very unwieldy to use in the clinic. The training taught me to make sure you have the linkages and causations clearly laid out.” – Dr Joseph Bateman, Medical Director, Christ Hospital, DoctusTech App User


Clinicians can justify the RAF score impact of those diagnoses by supporting them with appropriate documentation that meets the MEET criteria. When there is an audit (When, not If), their charts are proper and in order, and their patients are well cared for.


Rather than diagnosing “diabetes” a DoctusTech educated physician would instead test for complications and diagnose a specific disease condition, accurately reflecting the capitated payments for that person’s care. The behaviour change comes from switching from one ICD-10 code that doesn’t risk adjust to a more specific diagnosis, using a different ICD-10 code that does adjust the risk of that patient and accurately reflects the change in capitated payments for their care.


Book a demo today, and experience DoctusTech Mobile App’s transformative teaching techniques for yourself!

DoctusTech Helps Value Based Care

Value-Based Care is a natural movement toward the benefit of the patient with a reduction in costs by aligning all incentives in the right direction. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training?  Value-Based Care is for patients, and for the providers who care for them.

The market is now moving towards building value-based care drivers to all types of patients outside of Medicare Advantage. It’s unlikely a brand new risk model will be born for commercial patients. Therefore, all physicians will need to understand the risk adjustment models and the implications of documentation accuracy for reimbursement.

Why is HCC Coding Important for Value-Based Care?

HCC coding’s importance is less about the impact on revenue and more about the shift towards VBC models, which have consistently shown better clinical outcomes at lower costs. And Hierarchical Condition Category Coding is the language clinicians use to document the diagnoses of chronic conditions and the complications and various disease states that contribute to risk.  

Why should doctors care about HCC coding?

Doctors should, first and foremost, care about patients – and they do. But as a mechanism of that care, doctors must diagnose with specificity and document with accuracy in order to provide care and the revenue that affords that care. And HCC coding is how that is done. HCC coding is the documentation foundation for most of the value-based care arrangements used today. With “value-based care” usually being equated with Medicare Advantage, in coming years we believe that VBC will be incorporated into nearly all types of financial models.

HCC coding falls under the broader term of Risk Adjustment (RA) models for prospective payment. These models are designed to determine risk scores and assign a fee according to the patient’s level of risk.

In the Medicare Advantage world, these models use certain demographic and HCC codes to assign a risk score to patients known as an RAF. The assumption is the sicker the patient, the higher the RAF, the more dollars it will take to care for this patient during any given year. Therefore the RAF score of any patient population will determine the prospective payment Medicare disburses.

This prospective payment model based on RAF does 2 things:

  1. Aligns physician incentives. Currently, clinicians make money from taking care of sick patients. The sicker the patient, the more visits, tests, surgeries they have to do, and the more they are reimbursed. In this model, clinicians are incentivized to keep patients healthy and therefore require LESS tests and surgeries.
  2. Spurs clinical innovation the right way. Right now, pharmaceuticals and medical hardware companies are all trying to find ways to treat diseases. The newer the drug or medical device, the more revenue they make. In this model, healthcare groups are incentivized to find new ways of preventing the disease progression from ever needing the latest drug or newest medical surgery equipment.

How can DoctusTech Help?

We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.

DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement.

You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization.

CVS Health to purchase Signify Health for $8B

In an effort to strengthen its presence in the healthcare technology sector, CVS Health has announced plans to acquire Signify Health for $8 billion. CVS will be acquiring Signify from private equity firm TPG and other Signify shareholders. As a result of this acquisition, CVS will now have access to Signify’s enterprise-grade software solutions for clinical assessment, population health management, care coordination, and patient experience monitoring. Given that Signify is a provider of telemedicine services, the combination of these two companies will give CVC a greater nationwide presence. For example, CVS has 2,300 retail locations where it could place telemedicine kiosks or stations.


And remember, it was just mid-February 2022 that Signify Health announced plans to acquire Caravan Heath for $250 million with $50 million in additional payments depending on performance. This previous merger created one of the nation’s largest provider networks engaging in risk-based payment models. So with the Signify acquisition, CVS will be gaining a considerable share of the Medicare Advantage market, making them one of the biggest players in value-based care. 

Why is CVS making this acquisition?

CVS Health’s acquisition of Signify Health will expand its telehealth offerings, increase its reach in the healthcare market, and support its aim to become a one-stop shop for healthcare and health insurance services. Currently, Signify works with approximately 100 health systems and approximately 1,000 physicians. CVS Health currently offers health insurance, retail pharmacy, and other nonclinical services. By bringing Signify on board, CVS Health will be able to connect Signify’s technology with its retail locations to provide customers with a one-stop shop for their healthcare services. CVS Health is also aiming to expand its product offerings to include prescription delivery and doctor’s appointments. If successful, these efforts could further shore up CVS Health’s position in the healthcare market amid an increasingly competitive environment.

What does CVS get from Signify?

With the acquisition of Signify, CVS will gain access to a variety of healthcare products and services. These include enterprise-grade clinical assessment software, population health management services, care coordination software, and patient experience monitoring solutions. The clinical assessment software helps healthcare organizations identify gaps in their care delivery process, while the population health management software enables them to understand their patients’ needs, preferences, and health goals. The care coordination software is used to enhance communication between physicians and patients, while the patient experience monitoring solutions provide real-time insights into patient-facing services.

What does Signify get from this acquisition?

As mentioned above, Signify Health is a telemedicine services provider. It uses AI-powered technology to connect patients with healthcare professionals via virtual consultation. By acquiring Signify Health, CVS Health will be able to expand its telemedicine services to an increased number of customers. CVS Health’s acquisition of Signify Health will increase its reach in the healthcare sector, allowing it to deliver cost-effective and convenient care to a larger number of patients nationwide. In particular, CVS will be able to provide patients with greater access to its pharmacy services.

What does this mean for consumers?

CVS Health’s acquisition of Signify Health could mean greater convenience and lower costs for patients. The health insurer is in the process of integrating Signify’s technology into its own platform. Once this is complete, customers will be able to connect with medical professionals via virtual consultation. These virtual consultations are expected to be offered at CVS Health retail locations or online. Currently, CVS’s customers must travel to its retail locations to access prescription medication and professional health advice. With the Signify acquisition, the health insurer hopes to allow customers to access prescription delivery, health advice, and virtual consultations from a single platform. This is expected to reduce travel costs for customers and enable them to receive quick and accurate health advice from medical professionals.

How will this benefit TPG?

TPG is a private equity firm that has been investing significantly in the healthcare sector over the past decade. Currently, TPG owns approximately a 45% stake in Signify Health. The health insurer’s acquisition of Signify will enable TPG to receive an attractive exit. This exit could come in the form of a cash payout or a partial cash-and-stock transaction. CVS Health’s acquisition of Signify Health is expected to close during the second half of 2019. Once the acquisition is complete, TPG will be able to reap the benefits of its substantial investment in Signify Health.

Final Words: Will we see more healthcare mergers?

CVS Health’s acquisition of Signify Health is the latest in a series of healthcare mergers and acquisitions. For example, in April 2019, CVS Health announced that it would be acquiring Aetna for $69 billion. As the healthcare industry becomes increasingly competitive, we can expect that more mergers and acquisitions will take place. These acquisitions may involve healthcare providers and technology companies or pharmaceutical companies and health insurers. As the healthcare industry undergoes these changes, we can expect to see new healthcare delivery models and solutions emerging. And, with mergers and acquisitions, these solutions can be brought to market faster and at a lower cost.

DoctusTech Helps: Decrease Clinician Workload

In December of 2021, the Mayo Clinic published an alarming report: ⅓ of physicians surveyed intended to reduce their work hours – that represents 336,000 doctors. While—and I hope you are sitting down—1 in 5 physicians intended to leave their practice altogether – 20%, or 204,000


The cause? Burnout. 

Burnout from workload, COVID-19–related anxiety/depression, and fear of contracting the disease. Now, some of those burdens have certainly eased over the past 10 months – but the prevailing concern of burnout from overwork has hardly abated.

Burnout is a widespread problem in any industry, but the stakes are even higher in healthcare with lives of patients on the line. Quality and safety of care is our top priority and errors or lack of awareness can lead to terrible consequences.

With burnout on the rise and VBC/HCC knowledge requirements continuing to grow, it can feel like there is an impossible riptide in front of today’s clinicians. And with healthcare relentlessly marching in the direction of Value-Based Care, it’s no wonder why new clinicians have a difficult time onboarding. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.

The DoctusTech HCC Coding App is designed with a sole purpose in mind: to reduce clinician workload, and make it easier for them to diagnose, and ultimately, take care of their patients.

The Socratic method, clinical vignettes, and question and answer sessions are the most effective methods for capturing long-term knowledge. This is how doctors were taught in the first place, and this is the best way to do it. With DoctusTech, they can learn HCC coding in the same manner—from other doctors using clinical vignettes—on their own time, requiring only an average of five minutes per week.

The DoctusTech Mobile App is based on our successful HCC education and retention strategy, which relies on clinical vignettes customized to the clinicians’ weaknesses and strengths, which are sent to their mobile phones every week. With an engagement rate of 90%, DoctusTech App results far exceed any other learning tool, technology, or strategy.

After using the app for HCC coding education, clinician RAF accuracy is consistently increased based on the learning data.

What methods does the app use to accomplish this?

Our app gamifies the learning experience, connects clinicians with one another, allows them to compete for real prizes, and provides administrative support. In addition, the most advanced HCC code search tool in the world is available. Clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!

If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most. 

To learn more, book a conversation with our team!

DoctusTech Helps: Deploy HCC coding education across your organization

HCC coding improves the quality of patient care and reduces the cost of healthcare. But, like any tool, it’s only effective if the people who use it have it mastered. That’s why it’s so important to provide HCC coding education across your organization. In this article, we will share how DoctusTech helps deploy HCC coding education across your organization.


At DoctusTech, we are always eager to assist healthcare organizations boost HCC training programs. We believe that solving the three shortcomings of risk adjustment—the data gap, the workflow gap, and the knowledge gap—is critical. Most available solutions address only the data or workflow gaps. However, if your clinicians don’t have the right knowledge, you won’t obtain the outcomes you desire no matter what you do to resolve the data and workflow issues. We strongly believe that if you resolve HCC coding knowledge challenges, your data and workflow issues will be resolved along the way.


The DoctusTech Mobile App is designed on our successful HCC education and retention strategy that relies on clinical vignettes customized to the clinicians’ strengths and weaknesses, which are sent to their mobile phones every week. With a 90% engagement rate, DoctusTech App results far surpass any other learning tool, technology or strategy.


According to the learning data, we consistently achieve a significant increase in clinician RAF accuracy after they start using the app for HCC coding education. 


How does the app achieve this?


Clinicians can use our app to gamify their learning experience, engage with their peers, compete for real prizes, and receive administrative support. Our app also comes with the most sophisticated HCC code search tool available on the planet. In addition, clinicians earn 25 CME hours every year as they learn HCC coding in a non-boring app!


Clinical Vignettes – The secret sauce!


Most doctors who have just graduated from medical school or residency programs know little to nothing about coding for risk adjustment and value-based care. In the past, these clinicians were forced to sit in seminars and learn the correct codes so they could diagnose and document them properly. Every other important medical fact is learned in clinical vignettes, so clinicians have difficulty retaining and applying information learned in boring seminars or email blasts. Simply put, incorporating new HCC codes into daily practice is hard – which is why the DoctusTech HCC coding education app is so vital. 


Doctors prefer to learn using the Socratic method, clinical vignettes, and question and answer sessions, because it is the most effective way to capture long-term knowledge gain. This is how they were educated, and this is the best way. DoctusTech enables them to learn HCC coding in the same manner—from other doctors, using clinical vignettes, on their own time, requiring only an average of five minutes per week.


Get in touch to learn more about how DoctusTech helps!

DOJ Joins Cigna Medicare Advantage Fraud Case

DOJ joins fraud case agsinst Cigna Medicare Advantage Fraud Case

DOJ jumps into yet another False Claims Act lawsuit, this time regarding the Cigna Medicare Advantage Fraud Case. The Department of Justice has joined a False Claims Act lawsuit against Cigna Corp. that alleges the health insurance provider exaggerated the illnesses of its Medicare members in order to receive higher payouts from the federal government. 


Cigna Medicare Advantage, a subsidiary of Cigna, was sued in New York federal court in 2017 for defrauding the federal government of $1.4 billion by providing incorrect diagnostic codes from 2012 to 2019. According to the complaint, Cigna defrauded the federal government by providing incorrect diagnostic codes based on health conditions that patients did not have or that were not found in any medical records.


Earlier this month, the court granted the Justice Department’s motion to intervene in the case in particular regarding allegations that Cigna billed Medicare for risk-adjusted payments based on diagnoses that did not include testing, imaging, or other necessary clinical steps.


Cigna Medicare Advantage Fraud Case: a failure to document.


According to the Department of Justice, no Medicare Advantage patients received any treatment for these conditions during home visits or from any other health care provider during 2018. The DOJ initially decided not to join the case in February 2020, but reserved the right to do so. They have until September 30 to file their own case or enter their own complaint. The federal government intervenes less than 25% of whistleblower cases. DOJ joined Medicare Advantage fraud lawsuits against insurance firms UnitedHealth Group and Anthem in 2017 and 2020, respectively, on the same grounds. 


According to the Centers for Medicare and Medicaid Services, improper payments from these plans amounted to $16.2 billion in 2020, or 6.8% of all Medicare Advantage.

DoctusTech Helps: Increase RAF Accuracy

“I don’t care if the RAF goes up or down, I only care if it’s accurate.”

Dr. Farshid Kazi, Co-Founder, DoctusTech


If an organization is caught over-coding, up-coing, diagnosing conditions that either do not exist or are not supported in the chart, the cost of these errors can be very high. Audits are no longer just for health plans, provider groups like Sutter, Kaiser (and many others) have also been audited by the DOJ and hit with heavy fines.


On the other side of the board are many plans and provider groups that are struggling to diagnose and accurately document chronic conditions that truly do exist and risk adjust, leading to poor performance in VBC contracts and clinician burn-out. 


RAF accuracy is achieved through a perfect balance of accurate diagnosis and accurate documentation. 

What is Risk Adjustment Factor Scoring

Risk adjustment factors are used to estimate the expected outcome for a patient based on a number of different factors. One important factor is the patient’s age; other factors include socioeconomic status and comorbidities such as chronic illnesses or conditions. Each of these can be scored to give a single risk adjustment factor score. 


DoctusTech Enables 30% Rise in RAF Accuracy


We teach clinicians how to think about chronic conditions, improve diagnosis at the point of care, and help documentation and HCC coding – all in a lovable mobile app. And not only do clinicians learn how and what to code, the app is also the most powerful HCC code finder in the palm of your hand. Look up the code through a variety of intuitive queries, by tests that might indicate a diagnosis, and by related conditions – complete with complexities and branch-points to help drill down into greater specificity. 


While we cannot share sensitive client data, we can confidently state that a 30% increase in RAF accuracy is well within the normal range for our clients. 


DoctusTech Helps by Boosting Clinician Knowledge and Changing Behavior Just by Engaging With a Lovable Mobile App

The app uses the classic learning technique we all grew to know and love in med school: the Socratic method. By posing questions within a clinical vignette, clinicians learn—and remember—how to diagnose, code and document for risk adjustment. By increasing the fund of knowledge around diagnosing chronic conditions, the app improves unique code capture and documentation, boosting RAF accuracy over a very short period of time. After the initial self-assessment, clinicians are only asked to spend about five minutes per week engaged on the app, and behavior change outpaces traditional HCC teaching techniques by a significant margin. 



DoctusTech HCC Integrated Platform


Instead of clinicians having to go to various external data sources to gather information, DoctusTech’s HCC integrated platform, HCC 360, consolidates all data sources and presents them to clinicians while they are writing progress notes. Here’s how you can achieve greater RAF accuracy with DoctusTech:


Improve Patient Visits: Based on your patient’s chart, get real-time prompts for questions to ask or labs to consider.


Automate Chart Review: Translate your patient’s chart into HCC code using our A.I. in seconds, based on evidence-based medicine.


Faster Progress Notes: You won’t have to wade through third party portals or paper suspect codes anymore; we bring all sources into your EMR to simplify your life.


As healthcare continues to evolve, it is crucial that providers get educated and improve their skills in using HCC codes. DoctusTech is a revolutionary new way to improve the accuracy of HCC coding by making sure you know exactly how to code each condition. Our simple mobile app that engages clinicians in an easy guided learning experience while they file HCC coding notes. After only five minutes of training, clinicians can quickly and accurately code their own charts and boost the accuracy of their efforts.


Amazon Announces Plans to Buy OneMedical

Amazon has announced plans to buy OneMedical for $3B. OneMedical is a brick and mortar plus digital healthcare marketplace that operates in several major U.S. markets. The acquisition is Amazon’s latest move in the healthcare sector, and analysts say it could be a sign of bigger things to come. This is not Amazon’s first foray into the healthcare market, but after the Haven experiment closed down, the company has kept a relatively low profile while it tests new business models. In June, Amazon was among several investors that participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm that offers an edge security service for cloud networks and internet-facing applications and services. A few months earlier in March, news broke that Amazon had hired former pharmaceutical executive Bernard Jegou as its new vice president of e-commerce strategy and new business development. 


And in a very public failure back in 2017, Amazon partnered with Berkshire Hathaway and JPMorgan Chase to form an independent healthcare company called Haven, which it quietly scuttled mid-pandemic, February, 2021. Read on to learn more about how this acquisition could indicate continued interest from Amazon in the healthcare space — or if it is just another pivot from one of its many subsidiaries.



What is OneMedical?

OneMedical is a primary care practice and digital healthcare marketplace that uses technology to reduce healthcare costs and increase convenience for patients. The company has built a network of more than 500,000 doctors and has partnered with health insurance providers across the country to serve more than 3 million members. OneMedical offers a range of services, including access to an online portal for patients and a concierge service for their members. OneMedical’s network of doctors comes from a variety of specialties, including general practice, pediatrics, OB/GYN, and family medicine. OneMedical also offers telemedicine services, including video visits with doctor consultations and prescription refills.



Why might Amazon be buying OneMedical?

While Amazon has not released any details about why it is acquiring OneMedical, analysts say this acquisition may be a sign that the company has larger ambitions in the healthcare sector. Amazon has a track record of acquiring companies in sectors where it sees potential for disruption and then gradually building out its business there. This could be a way for Amazon to expand its e-commerce business into health insurance. It could also be a sign that Amazon wants to become a one-stop shop for healthcare services. Amazon has been experimenting with new business models in the healthcare space for several years now. The partnership with Berkshire Hathaway and JPMorgan Chase formed an independent health company called Haven began with promise, but was quietly closed a few short years later. And in June, news broke that Amazon had participated in a $35 million funding round for Zscaler, an Austin-based cybersecurity firm whose edge security service could help internet-facing applications and services like those that run on Amazon’s AWS platform.



Possible reasons for the acquisition

Analysts say there are a few reasons why Amazon might be interested in acquiring OneMedical. Amazon may be looking to expand its reach into healthcare marketplaces beyond its partnership with Berkshire Hathaway and JPMorgan Chase to form an independent health company called Haven. Acquiring OneMedical could give Amazon a foothold in the digital healthcare space, which has been growing rapidly. Amazon could also be interested in OneMedical’s digital platform for its members. Having an online presence and digital tools for patients and doctors could let Amazon expand into other healthcare sectors, including pharmacy. And Amazon might be interested in the data that OneMedical has on its members, which could be useful for the company’s future endeavors in the healthcare space.



Amazon has bigger plans in healthcare

Analysts say the acquisition of OneMedical could signal Amazon’s intent to become a major player in the healthcare space. It is unclear exactly what the company’s strategy will be, but it is likely that Amazon will focus on improving the customer experience across the healthcare sector. Amazon is no stranger to industries with high-barrier-to-entry business models. The company has made inroads in industries such as grocery and e-commerce, as well as more traditional businesses such as manufacturing and cloud computing. Amazon has long been a disruptive force in the retail sector. The company has reshaped consumer expectations of online shopping and shifted the entire retail landscape in its wake. The company’s foray into digital and bricks-and-mortar retail has been a boon for customers, and it has also provided a boost for shareholders: Amazon’s stock is up almost 102% over the past year.

Value-Based Care and Risk Adjustment

Experts say that Amazon’s involvement may help OneMedical’s risk management as the adoption of more value-based care programmes continues. Most of One Medical’s business has traditionally been generated from charging commercially insured patients per-visit fees, but since the acquisition of Iora last year, Medicare patients are now served, and revenue is captured as a result of savings through risk contracts. According to their website, OneMedical serves scores of Medicare Advantage plans, though patient numbers were not readily available. Scaling value-based care is challenging for providers without extensive data experience. Those in primary care, retail health, and telehealth should be concerned, experts say.



The big question: Is this a pivot or a sign of future intent?

Analysts say Amazon’s acquisition of OneMedical may be a sign that the company is pivoting from its health technology investments, like Zscaler, and looking to establish a more direct presence in the healthcare sector. But it is  also possible that Amazon has more ambitious plans in the healthcare space that the acquisition of OneMedical is only the first step in. Whatever Amazon’s end goal is in the healthcare sector, it seems likely that the company will take a slow and methodical approach to growing its business. After all, Amazon has plenty of experience building new businesses from the ground up, and it has a track record of entering new sectors and disrupting existing players with a more customer-friendly approach.

DoctusTech Helps Clinicians Learn HCC Coding

DoctusTech Helps Clinicians Learn HCC Coding

DoctusTech helps clinicians learn HCC coding through clinical vignettes in an app that is fun and engaging. Diagnosing with the appropriate HCC code is a critical skill for modern clinicians who care for patients in a value-based care arrangement. You cannot treat what you do not accurately diagnose, and you cannot afford to treat what you do not appropriately code. Without the correct diagnoses and accurate documentation and coding, caring for patients with complex disease will be unsuccessful, leading to increased avoidable hospitalizations and increased cost to the organization. 


And without a tool to get clinicians quickly up to speed on diagnosing for risk at the point of care, coding accurately and documenting correctly, you will be stuck. Stuck in boring seminars that rarely affect lasting behavior change; stuck with missed diagnoses and missed revenue targets; stuck with patients missing out on essential care; stuck with overworked clinicians; stuck. 


How do clinicians learn HCC coding?

This is where DoctusTech Helps. We provide a modern learning tool for the modern clinician, using gamification, competition, real prizes and administrative oversight to see who is engaging and who needs a little extra help. Also, our app deploys all the subtle nudges and complete with the most advanced HCC code search tool on earth.


And clinicians earn 25 hours of CME per year, while they learn HCC coding in a non-boring app!


In SCUBA diving, the diver must add just the right amount of weight to maintain perfect positive buoyancy; too much and you will sink, too little and you will bob on the surface like a cork. Risk adjustment in value-based care has some similarities: a successful VBC program will diagnose and treat just the right conditions. Not over-coding, and not under-diagnosing. 


Clinicians learn HCC coding better in clinical vignettes

And doctors coming out of medical school and even residency programs know little to nothing about HCC coding and diagnosing for Risk Adjustment and Value-Based Care. Traditionally, these clinicians sit in seminars getting force-fed codes in an effort to teach them how to accurately diagnose and document with the appropriate HCC codes. Unfortunately, this is not how every other vital piece of medical information was learned, so clinicians struggle to retain the information and utilize it in daily practice. 


Medical education is all about the Socratic method, question and answer, clinical vignettes. Doctors learned to learn this way, and they prefer it. Which is why DoctusTech helps doctors learn HCC coding the way they like to learn – from other doctors, in clinical vignettes, on their own time, and in an average of 5 minutes per week.


Truly, DoctusTech helps clinicians learn HCC coding. And when clinicians master diagnosing for risk with HCC codes, your whole VBC program improves. 


See more ways that DoctusTech Helps:

  • DoctusTech Helps: Increase RAF Accuracy
  • DoctusTech Helps: Decrease clinician workload
  • DoctusTech Helps: Deploy HCC coding education across your org 
  • DoctusTech Helps: Change Clinician Behavior
  • DoctusTech Helps: Value-Based Care

Everything You Need To Know About HCC Coding Training

Everything You Need To Know About HCC Coding Training

Why is HCC coding training important? Without proper coding, it is impossible to diagnose accurately, treat effectively, document those diagnoses, or achieve revenue goals. Coding training will help you master the skills you need to properly code patient records, so investing in HCC coding training might be the right move for you! Read on to learn more about HCC coding training!


What is HCC coding?

Hierarchical condition category (HCC) coding was created to estimate future health care costs for patients. The Centers for Medicare & Medicaid Services (CMS) HCC model was established in 2004 and is increasingly being used as value-based care gains traction. The HCC model relies on ICD-10-CM coding to assign patients risk scores based on their medical condition. Each condition is associated with an ICD-10-CM code. For example, a patient with few serious health problems is likely to have average health care costs for a specific period of time. Patients with many chronic conditions, however, are more likely to have higher health care utilization and costs.


Why is HCC coding training so important?

As we mentioned above, proper healthcare coding is important for a number of reasons. However, even the best healthcare providers cannot properly code without the right training. If you are new to the healthcare industry, you will need training to learn the coding system and understand the complexities of accurate diagnosis and documentation. If you have been in the industry for a few years but have not kept up with the latest coding trends, you may also need training to refresh your skills. Whatever your situation, it is important to take the time to invest in HCC coding training. This training will help you master the terminology and coding systems that are used in the healthcare industry. It will also help you learn how to properly diagnose and document for better patient care.


Which platforms and tools are effective?

HCC coding training can be delivered in a variety of ways. Depending on which courses you decide to take, you may be able to access them online or on your mobile device. Most HCC coding training courses will include videos, interactive activities, and practice tests. These tools can make learning easier and more effective. They can also help you retain the information you learn effectively. If you are looking for HCC coding training, it is important to find a platform or a course that fits your learning style and skill level. If you are new to the industry, you may want to take a beginner’s course. If you have been in the industry for a few years and just want to refresh your skills, you might want to take an intermediate or advanced course.


3 Things to include in your training plan

When you are ready to start your HCC coding training, it is important to make sure you have a plan in place. This will help you stay motivated and on track and make sure you finish before the course’s deadline. There are a few things you should definitely include in your plan.


Set specific goals

Before you begin coding training, you should sit down and set some specific goals for your course. What do you hope to achieve by the end of your training? By setting specific goals, you will know what you are working towards and have something to motivate you. 

Set a schedule

It is important to set a schedule and stick to it. This will help you stay motivated and make sure you do not get overwhelmed by the coursework. Make sure you allot enough time for studying each week and do not try to cram. A healthy pace is achievable at 5 minutes per week, if you have the right tools. 

Stay focused

Finally, during your coding training, it is important to keep your eye on the prize. While coding is interesting and can be complex, you do not want to get so involved that you lose sight of your goal. Stick to your schedule, do not try to push yourself too hard and you will be on track to finish in time.


Get Started Today

Doctus Tech is the best way for clinicians like yourself to start learning to diagnose with HCC codes. Benchmark yourself with other clinicians, identify your team’s knowledge gaps and benefit from a 30% increase in RAF accuracy. Sign up for a 14-day trial now!

Risk Adjustment Coding – Challenges And How To Get It Right

Risk Adjustment Coding

Risk adjustment coding is a vital part of any managed care organization. It helps to ensure that patients are appropriately diagnosed and documented accurately according to risk level, which in turn allows the organization to receive appropriate capitated payments to provide all the care needed to reduce avoidable hospitalizations and achieve maximum health. And regardless of how  challenging and time-consuming it can be to implement, getting it right is vital on many levels. Diagnosing and coding for risk can be tricky. 


It is not always obvious how complex and risky a condition is, especially because some patients are at higher risk than others for diseases like depression or schizophrenia, but many conditions can be difficult to diagnose. Those who appear low-risk might actually be high-risk, once you dig deeper into the specific diagnosis details. There are thousands of potential codes and conditions to diagnose that can be used to determine risks. There is no perfect formula for every managed care organization; you have to find protocols for training and improvement that work best for your clinicians and operators. Let’s take a look at some of the challenges involved in risk adjustment coding and how to get it right.


Determining risk is difficult

When implementing a risk adjustment program, make sure you have a team on hand with strong coding and data management skills. These team members should be able to look at each patient record and determine both the conditions that have been diagnosed as well as the documentation criteria to be  applied to that patient in the chart. This team will be responsible for determining and documenting  diagnoses that correlate to the risk level of each patient. This task can be difficult since mastering HCC coding for risk adjustment requires a lot of learning and is often different than standard ICD-10 coding. But there are modern tools for mastering this, so do not lose hope.


Risk adjustment requires a lot of data

Risk adjustment also requires a lot of data. The more information you have about each patient, the better you are able to diagnose based on their true conditions and related risk. If you do not  have enough data about a patient, or lack consistent data throughout the lifetime of a patient relationship, you will have a hard time determining their true risk level. 


For example: Patient A has been a patient for 10 years, and Patient B has been a patient for 2 years. If you’re trying to diagnose the patients, you’ll have to take into account their lifelong risk factors and current health status. This includes things like socioeconomic status, age, family history of certain diseases, how much they smoke, and more. If you have a few years of data points on Patient A, and only a few months of data points on Patient B, you’ll be able to diagnose Patient A more accurately.


Coding errors are common

Coding errors are common in risk adjustment, but they can be avoided with consistent training, accountability, strict internal audit procedures, and improved clinician buy-in. Coding errors can lead to overcharging or undercharging the CMS, resulting in either missed earnings or painful charge-backs. Coding errors can be caused by a number of different factors. For example, mistakes could be made when determining which diagnoses apply to patients, which codes to use for the diagnoses, or what to document to justify the diagnosis in the chart. Diagnoses require clear communication as well as consistent documentation on all patient records.


It is only going to get harder.

The bad news is that risk adjustment is only going to get harder. New technologies like AI, voice recognition, and machine learning are changing the way health care providers analyze and manage data. While these technologies will make many aspects of coding and managing data easier, they will also make it more complex by introducing even more variables and data points to consider. So while risk adjustment could be more challenging, there are tools available that simplify the process both in training and inside the EMR.

[Book a Demo]


Risk adjustment is vital, because it ultimately determines what type of care an individual patient needs and how much risk the organization is taking on, managing that care. It is important to ensure that your organization is accurately diagnosing and documenting so that patients stay healthy and your organization has the needed revenue to manage their care.

The Intricacies of Value-Based Care: A Step by Step Guide

Value-Based Care is a game-changing advancements for patients and the providers who care for them. Value-based care is revolutionizing  the healthcare industry and aligning incentives more and more each year. The concept of pay-for-performance, patient-centered care, and outcome measures have all been developed with the intention of providing more value to patients and healthcare providers alike. These new standards are also a response to the Affordable Care Act’s emphasis on cost containment and value in healthcare services. Therefore, it is no wonder that many hospitals and medical practices have adopted a value-based approach when considering how best to meet the needs of patients and the business needs that make care happen. However, navigating this new territory can be challenging without proper guidelines.


What is Value-Based Care?

Value-based care (VBC) is a system of payment designed to change the incentives for healthcare providers, so that they are rewarded for providing high-quality, cost-effective care. In VBC, providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. Similar to the H and R Block tax model, providers are rewarded for going above and beyond what is expected of them. VBC providers are rewarded for providing high-quality and cost-effective care, whereas higher cost or decreased patient outcomes  can result in  financial penalties. 


This is a significant change from the fee-for-service model that has long been the primary financial model for  healthcare. In the fee-for-service model, healthcare providers are reimbursed based on the number, kind and cost of procedures and services provided to patients. More expensive procedures make providers more money, even when not medically necessary. And care that is shown to benefit the health of the patient but does not directly result in revenue for the practice is not financially viable and often gets overlooked (e.g. care-coordination, regular nurse follow-ups, ancillary services, nutrition, transportation, counseling, remote patient monitoring, and so many more).


The Basics of Value-Based Care

Value-based care is centered around the idea that quality and cost should be the focus in providing healthcare services. As such, it is the responsibility of healthcare providers to optimize the care they provide in terms of both quality and cost. This can be achieved by looking at the overall cost of care, rather than just the cost of the single procedure. The shift from volume to value in healthcare has been occurring over the past two decades. There have been many policy changes and legislative initiatives aimed at reducing healthcare costs by focusing on quality. Key indicators of the shift from volume to value include: The Balanced Budget Act of 1997; The formation of the Medicare Payment Advisory Commission (MedPAC); The creation of accountable care organizations (ACOs);  The Affordable Care Act (ACA).


Key Strategies for Transforming to a Value-Based Care Environment

While the overarching goal of value-based care is to reduce healthcare costs while maintaining or improving quality, there are several strategies that providers can employ to make this transition. 


  • Look at the big picture: Value-based care requires providers to look at the big picture of healthcare costs, which includes both the costs of the care being provided as well as the costs of delivering the care itself. 
  • Focus on the patient: Value-based care should focus on patients and how they can expect to be treated. The focus should be on patient satisfaction scores and more personalized care. 
  • Improve the care delivery process: By improving the care delivery process, providers can reduce errors and make it easier for patients to receive the care they need.


Who Is Responsible for Value-Based Care?

A number of different stakeholders are responsible for enacting value-based care at each step along the continuum of care. At the patient level, patients themselves play a critical role in the success of VBC. Patients should be providing honest feedback on the quality of care they receive and the outcomes they experience. Healthcare providers are responsible for coordinating the collection of data, assessing the value of the care they provide, and reporting on the outcomes of their services. Finally, payors are charged with using the information from providers to make risk-adjusted payments.


Identifying the Right Measures and Outcomes

As previously discussed, VBC providers are reimbursed based on the relative value of their services. The amount a provider is paid is based on the quality and outcomes of the services provided as well as their costs. In order to determine the relative value of a particular service, providers must first select the appropriate outcome measures. 


In selecting outcome measures, providers should consider the following: 

  • Is this outcome measure important to patients? 
  • Is this outcome measure accurate? 
  • Is this outcome measure feasible to collect?


Other Strategies to Consider: Staffing, Infrastructure and Technology

Beyond the strategy of selecting the right outcomes and measures for VBC, providers should also consider the following strategies when endeavoring to improve the delivery of quality and cost-effective care. 


  • Staffing: There are a number of strategies that providers can employ to improve staffing outcomes, such as considering the optimal staffing mix, providing on-the-job training, and leveraging digital technologies to improve efficiency. 
  • Infrastructure: In addition to factors such as the condition of the building, providers should also consider the functionality of their facilities, such as the accessibility of their services or the location of their facilities. 
  • Technology: Providers should also consider the technologies they have in place, such as EHR systems, scheduling software, HCC coding education apps, and diagnostic equipment.



There are many benefits to adopting a value-based care approach. VBC providers are beginning to see improvement in outcomes, such as fewer avoidable hospitalizations, reduced readmission rates, increased patient satisfaction scores, improved quality scores, and lower mortality rates. Furthermore, providers who embrace VBC are actually seeing  bottom-line financial benefits, as they are rewarded for providing high-quality, cost-effective care. However, adopting a value-based care approach is not without its challenges. In particular, providers must be willing to take a critical look at their current practices and begin to change where necessary. Along the way, providers should be transparent with their patients about the changes they are making, the things that are being actively improved, and the over-arching WHY behind their shift to Value-Based Care. 


Value-Based Care is a natural movement toward the benefit of the patient. And as providers make the shift, patients will be encouraged both by the motive behind the transition as well as the improvement in their overall health and the reduction in the costs of their care. Truly, Value-Based Care has the potential to be a significant win-win for patients and providers. And in the end, isn’t that why you spent all those years pursuing your medical training?  Value-Based Care is for patients, and for the providers who care for them.

4 HCC Coding Education Strategies for Physicians

HCC coding education is a fast growing need for physicians. To meet the demands of today’s fast-paced and dynamic healthcare environment, many are now accelerating their transformation from a hospital-centered fee-for-service model to a more patient-centered model, and Value-Based Care is at the forefront of this change. The increased HCC coding knowledge requires clinicians to become more efficient with their time and resources as they are forced to master HCC coding in the gaps between patient care. 


The focus  on implementing coding education programs for clinicians is a hot topic. Unfortunately, many of the strategies being deployed actually add to the  challenges clinicians face in the day-to-day. They do this by attempting to educate with outdated methods, forgetting some of the tried-and-true teaching techniques that worked so well in med school. Namely, clinical vignettes deployed using the Socratic method.   In order to achieve the proficiency they need to code efficiently in real time, today’s clinicians need a solution that works well, without adding to their already stretched workload. 


Whether you are just getting started with your organization’s coding education strategy or you want to take it to the next level, this blog post compares the four key HCC coding education strategies, highlighting their strengths and weaknesses.


1. Lecture by Zoom / Classroom

The classic classroom setting, training through seminars deployed in person or over Zoom. This method does allow you to reach a massive audience and deliver identical content to them. 


If only doctors learned this way, it just might work! Unfortunately, most doctors come out of med school hard-wired to learn through clinical vignettes and the question and answer techniques, AKA the Socratic method.    Why? Because while some people do not learn well in a lecture setting, med school teaches doctors how to retain massive amounts of information using this proven teaching strategy. 


2. One-to-One Coaching

One-to-one coaching is the gold standard of HCC coding education. If there was one coach for every 5 clinicians, and if every clinician had time to be coached, this could work. And if every clinician learned the same way, it would work. But that is not the case! This strategy has its advantages. The sessions are intense and generally effective, as it results in an immediate correction to a clinician’s thought process. But this strategy will only work if clinicians have unlimited time and nearly unlimited coaches, which they do not. This method is super time-consuming, and do not forget, to organize this, you would need a massive staff to run the entire thing. Also, unlike Zoom classrooms, your reach is limited by  geography.


3. Email Blast

 Other than the fact that it does not work, it is great! Email is fast and easy, but also super easy to ignore. Whether you opt to  share all the codes in a single email, or drip out Code of the Month in a series of emails, it still falls flat. Easiest to deploy,  easiest to ignore, and hardest to retain. 


4. DoctusTech App

We admit to a certain bias, but hear us out. Learning can be done on  the doctor’s timeline,  and there is no scheduling required. Track the progress and performance, and help them to learn more and focus on areas needing attention. The DoctusTech app is ideal for larger groups, helping clinicians  learn without negatively impacting workload or patient care. JIT Learning enables clinicians to learn what they need when they need it. And without the limits of geography, the same HCC coding education can be deployed to all clinicians at once. No coaching staff to hire, train, deploy and manage. Accountability across the organization. Ease of use for clinicians with only a five minute lift per week. 


To make learning interesting, the app uses gamification to keep things competitive and fun. Clinicians can see how their peers are doing, and that competitive drive kicks in, pushing learners to engage even more. And when new information, rules, and codes come out, the app serves content to rapidly update the whole org. This app is cost-effective, saves time, and provides real-time behavior change.


HCC Coding Education Matters

No matter where you are in your value based care journey, HCC coding education is a vital tool that your clinicians need right now.


The best way to learn HCC coding is in the DoctusTech app. The second best way is deploying an army of coaches. And if you are still using email or seminars to onboard new clinicians and teach HCC coding to your doctors, please schedule some time with our team. The DoctusTech app is less expensive, more effective and far simpler to deploy, use, manage and maintain than any of the other HCC coding education strategies. 


Learn More about HCC Coding Education

Book a demo to see the best HCC coding education strategy in action.

5 Ways to Improve Your Revenue Cycle Management Strategy

Revenue Cycle Management

Revenue cycle management (RCM) is a hot topic this year. Monitoring, analyzing and improving the efficiency of your organization’s revenue processes is top of mind for leaders across many healthcare organizations. And you’ are probably still reading because you know that improving your organization’s revenue processes is essential to its success. But are you doing everything you can to implement a robust RCM strategy? Your competitors will not sit back and watch you take the lead. If you do not take action now, your competitors will leapfrog you with efficiency and better margins. . Read on for five ways that a strong RCM strategy will help improve your organization and drive financial success.


Build Strong Relationships with Partners

Revenue cycle management starts with strong relationships with your partners. This is especially true for organizations that rely on managed services or outsourcing partners to complete some or all of their revenue cycle activities. A strong partnership with your managed services providers will increase the likelihood that they will help you achieve your revenue goals. 


Partners are crucial to your success, so you must work to build strong partnerships with them. How can you do that? First, decide how your organization will work with partners. Then, clearly communicate that decision to all partners with which your organization does business. Strong relationships with partners will help drive success in all other areas of revenue cycle management.


Improve Customer Experience

One of the best ways to improve your customer experience is through managed services. Providers of managed services can handle many customer-facing activities, such as claims processing, that your organization might struggle to handle on its own. Doing so will free up your staff to spend more time on strategic revenue-generating activities. Strong relationships with managed services providers are also essential for ensuring that clients receive a quality experience. If managed services providers are not communicating with your clients in a helpful, empathetic way, your organization’s reputation will suffer. You can avoid these problems by clearly communicating with managed services providers regarding your company’s communication strategies and expectations.


Improve Diagnostic Accuracy and Specificity

One of the fastest pathways to improving revenue is to repair broken methods of diagnosing chronic conditions in risk contracts. Diagnosing very specifically, HCC coding correctly and documenting very accurately can provide not only a direct boost to revenue, but improves outcomes in patient care. HCC coding is vital to successful risk contracts, so RCM requires your organization to improve the actual fund of knowledge within your individual team members. If your organization is educating clinicians in seminars or zoom calls, emails and PDFs, you are missing out on the opportunity to improve diagnostic specificity and accuracy. And while accurately diagnosing can improve patient care revenue, inaccurate HCC coding can have dire consequences on your org’s bottom line. 


You might be hesitant to overhaul your HCC coding education, because it feels like a lot of work. However, it is far less of an organizational lift to improve training than it is to audit and fix errors along the way. And while some may claim that the new app-based HCC coding education is far less expensive than traditional training strategies, the real impact to revenue is cash flow positive. And that cost must be benchmarked against the inevitability of audits and repayments. Choose a partner you can trust to improve your team’s HCC coding, and see a direct impact to revenue, and simplification of the entire RCM process.


Monitor and Measure Key Performance Indicators

Management guru Peter Drucker once said, “Only what gets measured gets managed.“ No matter which areas of your revenue cycle you decide to focus on, you must monitor and measure your progress. This is critical for assessing the impact of your efforts and identifying areas where you might need to make changes. You can use metrics to measure customer experience, revenue cycle time, productivity, expenses and more. Choose the metrics that will help guide your RCM strategy the most. For example, customer retention and customer satisfaction metrics will be helpful for an organization that offers customer-facing products or services. RCM metrics that track the efficiency of your revenue cycle are also helpful for organizations that sell products and services. For example, tracking net revenue per customer and average revenue per customer over time can help you determine how well your revenue cycle is performing.


Automate Proven Processes

One of the easiest ways to improve your revenue cycle management strategy is to automate proven processes. If your organization is managing customer information, claims, billing or some other process manually, you are missing out on the opportunity to improve the process and save time and money. You might be hesitant to automate certain processes because you aren’t sure how they will work or if they will produce accurate results. If so, start small. Choose one process that you are confident will work as intended. Then, put the process into action. If it works as expected, implement it in other areas of your organization. If it does not work as planned, do not be afraid to scrap it and try something else.



Revenue cycle management is an essential strategy for all organizations. You cannot sit back and hope your revenue processes will improve on its own. It is the nature of RCM to get worse the moment you look away. You must take action to ensure that your organization is managing its revenue cycle as efficiently as possible. To succeed, you must work to build strong relationships with partners, improve your customer experience, improve diagnostic specificity and accuracy, monitor and measure key performance indicators, and automate proven processes. If you do, your revenue cycle management strategy will be strong and successful.

Check out our website https://www.doctustech.com/

4 HCC Coding Challenges All Clinicians Face

4 KEY HCC Coding Challenges Clinicians Face

As the U.S healthcare system transitions towards value-based payment models, independent clinicians and physician groups continue to face HCC coding challenges that not only impact their bottom-line, but patient care as well. On top of all this, the pandemic has added a significant burden to the already stretched clinician workload.


Here are 4 key HCC coding challenges clinicians are facing now, and how they can overcome them.


  1. Physician training for HCC coding – Physicians are already working tirelessly to provide excellent care to their patients. Asking them to learn HCC coding through brute-force via zoom calls, classroom seminars and email blasts is a bridge too far. On the other hand, the focus on value-based care has made it imperative for physicians to know and understand HCC coding so that they can accurately document patient records. So clinicians know they need to know, they just don’t have an effective and engaging mechanism for efficient and effective learning.


  1. Revenue impact due to incorrect coding – Accurate HCC coding is necessary for accurate reimbursements and patient care, and inaccurate coding can directly impact the bottom line. That is why it is imperative that clinicians and staff be well trained in HCC coding. And the complexities don’t stop there. HCC codes not only impact RAF scores, they also interact directly with patient care, and a fair level of decision support is required , as HCC codes are not intuitive.


  1. Poor HCC integration with EMR systems – When HCC coding does not integrate with the EMR, it creates a complex struggle for clinicians and physician groups. This not only leads to unintentional errors, but makes workflows more difficult and adds to the burden of an already heavy workload. It is critical to put a system in place that teaches clinicians to accurately document HCC codes on every patient, and integrates within the EMR.


  1. Lack of trained HCC coding professionals – Staffing shortfalls not only plague small practices, but larger physician groups are short-staffed as well. A lack of well-trained staff may be related to revenue or rising salaries, which sometimes small practices are unable to sustain. And when larger hospitals acquire smaller practices, a shortage of trained staff is often just one side-effect. Training clinicians and non-clinical staff on HCC coding is vital.


Transitioning to a value-based care model will never be seamless until these challenges are solved. How? With our unique suite of HCC education and EMR integration tools, enabling physicians to learn HCC coding and integrate an AI-powered HCC coding system into their existing EMR platforms to drive efficiency and accuracy.


To learn how our HCC coding app lets physicians train for HCC coding click here.


To understand how our EMR integrated platform works, click here.

HCC Coding and Physician Burnout

HCC Coding and Physician Burnout

RaDonda Vaught was just sentenced to three years of supervised probation. The former Vanderbilt University Medical Center nurse was found guilty of negligent homicide and gross neglect of an impaired adult in the death of a patient, because she administered vecuronium rather than Versed.


A tired, overworked nurse could not find the prescribed medication in an automatic drug dispensing cabinet, so she used an override and grabbed the wrong drug. Her patient died, and she was convicted of two felonies.


Burnout is a pervasive evil in any industry. But in healthcare, the stakes are measured in lives, and a career-ending error could also land a well-meaning provider in court, battling more than a malpractice suit. 


The Rise and Fall and Rise of Physician Burnout

A study from 2019 demonstrated a decline in physician burnout [Source]. Good timing, as the burnout decline preceded an overall healthcare worker burnout event rivaling the black plague at a drag strip. Just one year after publication, COVID-19 ushered in the worst, longest, darkest season of overwork, stress and burnout the healthcare industry has seen in a century. 


And with the industry marching predictably toward Value-Based Care, onboarding a new clinician comes with a massive learning curve. Requiring providers to add HCC coding to their already complex workflow is not only vital to improve the industry, it is increasingly mandated by CMS.


Add to it that none of this HCC coding was taught in medical school, and you have a perfect storm that even Clooney & Wahlberg would struggle to make sexy. 


Why do they make it so hard?

The rising tide of burnout and the steady growth of VBC and HCC coding knowledge form enough of a riptide of impossibility for today’s practitioners. But the teaching methods being used to bludgeon new codes into the weary minds—and workflows—of new residents and established docs alike are downright cruel. Consider that HCC coding education is  being deployed using some of the most arcane and ineffective teaching tools available today. 


1 hour seminars are the lingua franca across nearly every provider group in a risk payment model. And if sitting in a classroom being talked at while pretending not to stare blankly at your phone was not bad enough, the two worst years in most providers’ careers were met by shifting those interminable seminars to a Zoom call, probably on your phone.


Consider the vital role that HCC coding plays in capturing critical diagnoses to be treated, documenting those diagnoses to keep them treated, and billing against Risk Adjustment scores to reimburse for essential healthcare services that keep patients out of the hospital. 


And we are teaching these skills over a Zoom call? With providers more burnt-out than ever, and Zoom fatigue at a universal high – we are lecturing doctors on HCC coding over their phones? Is it a surprise that engagement is low? Is it a surprise that errors are high? Or that adoption of full risk models is sluggish at best? 


And yes, one-to-one coaching is the gold standard, and those who provide this mission-critical service should be heralded in the streets and welcomed with ticker-tape parades. This is heroic work. But with global workforce shortages, there are definitely not enough coaches to tackle the task at hand. Not for all the clinicians in desperate need of a rapid increase in their fund of knowledge on VBC and HCC coding. 


Is there really no other way? 


Full disclosure: this is a blog post by a brand that has pioneered another way to teaching HCC coding to doctors. And it really works. But we are not here to sell you our solution. At the moment, we are only here to say as loudly and as clearly as we can that Ye Olde Ways™ are not working. And if there is a better way—which there is—we need to be running toward it like actual lives depended on it. And not just patient lives – doctor lives, nurse lives, NPs and PAs and coders and operators and the IT team, too. There is a lot at stake, and it’s time to search for answers. 


Our Offer

If HCC Coding and Physician Burnout are at all on your radar, we’d love to share a solution to both. Better solutions are out there – and they outperform seminars and code-of-the-month email blasts for engagement and results. And they free up your coaches to focus on the 20% that need it the most. 

To learn more, book a conversation with our team!


Implementing Value-Based Care – A How To For Physicians

Value-Based Care

Implementing Value-Based Care is essential for today’s physician. Value-based care is a system of payment and reimbursement that rewards healthcare providers for delivering high-quality, cost-effective care to patients. There are two ways to improve the value of care: improving the quality of care (fewer complications, less re-hospitalization, shorter length of stay, better patient experience); and reducing the cost of care (more efficient services, fewer administrative costs, reduction in waste and overuse of services). 


What is value-based care?

Value-based reimbursement is a system that aims to reward healthcare providers for providing high-quality care at an affordable price. It is important to understand that value-based reimbursement is not the same as cost reduction. It is not about minimizing costs, but rather, it is about maximizing quality while keeping costs low.


Benefits of value-based care

Better patient outcomes and experience – Through improved value-based care, you will likely be able to reduce the number of complications, readmissions, and other negative outcomes that patients experience. 


Reduced costs – An effective value-based care program will not only result in higher quality, but will also likely reduce your costs. You will be reimbursed for all of the services you provide, but only for the ones that meet your quality standards.


Increased revenue – Providing high-quality care can lead to greater patient satisfaction, word of mouth referrals from happy patients, and thus, more revenue.


Better reimbursement – A value-based care program will be focused on providing high-quality care, so your reimbursement should be higher as a result.


A sustainable business model – If you want to keep your business open and sustainable into the future, you must be able to adapt to the changing needs of your patients, payers, and providers. In order to do this, you must be open to new ideas and be willing to try new strategies. The best place to start is with value-based care.


How to implement value-based care effectively

Start with the end in mind – Before you can implement value-based care, you need to have a clear plan and vision for what your new value-based care program will look like.


Educate your staff – One of the most effective ways to implement value-based care is to educate your staff. HCC coding is not taught in medical school, so clinicians will need a fast and effective means of getting up to speed. Accurate and specific diagnosis coding for risk management will ensure better patient care and improved revenue. And when clinicians understand HCC coding,  the process, the metrics, and how their work impacts these metrics, all of VBC just works better


Educate your patients – Another important aspect of implementing value-based care is to educate your patients about what it means and why it is important.


Measure the right things – The first step in implementing value-based care is to make sure that the metrics you are measuring are actually contributing to value.


Find ways to reduce costs – Although you want to increase revenue and improve reimbursement, you also want to minimize costs.


Find the right partners – Last but not least, you need to find the right partners to work with to implement your value-based care program. (We would love the opportunity to earn your partnership on educating clinicians on HCC coding, as well as integrating documentation accuracy and value-based diagnosis resources into your EMR. Get in touch to learn more.)

Measure outcomes and quality

Clinical outcomes – In order to determine if a patient is receiving high-quality care, you must be able to measure their clinical outcomes (metrics such as blood pressure, heart rate, blood sugar, or other lab values or diagnostic findings, e.g. pathology reports).


Patient experience – While clinical outcomes are important, they do not tell the whole story. Patients may be receiving high-quality care that is resulting in good outcomes, but they may also be receiving poor quality care that is resulting in bad outcomes.


Provider experience – In order to provide high-quality care, providers must receive high-quality training. In addition, they must have access to the right tools. If they do not, they will not be able to provide high-quality care.


Define your value-based care services

Identify your core services – Before you can define the value-based care services you will offer, you must first determine your core services.


Identify your add-on services – Once you have your core list of services, you can then identify add-on services that you offer patients but that are not absolutely required for them to receive care from you.


Assign value-based care units (VBUC) – Next, you must assign a value-based care unit cost (VBUC) to each service.


Create a menu of value-based care services – Once you have identified your core services and have assigned VBUCs to each one, you can then create a menu of value-based care services.


Summing up

Value-based care has the potential to transform healthcare in the United States. It is important to note, however, that value-based care is not a fad or trend that will quickly come and go. It is a system that has been around for decades and is continuously evolving as more is learned about what it takes to provide high-quality, cost-effective care to patients. If you want to survive and thrive in today’s healthcare environment, you must be willing and able to adapt to the changing needs of your patients, payers, and providers. The best place to start is with value-based care.