The U.S. healthcare system is undergoing a significant transformation, moving away from traditional fee-for-service models towards value-based care Program initiatives that reward providers based on the quality and efficiency of patient care. While this shift presents many opportunities, it also brings new challenges and regulatory risks for companies seeking to participate in value-based care program initiatives.
In recent months, there has been a lot of discussion around the emerging audit and compliance trends under value-based care. During the Rise National conference, Christi A. Grimm, the Inspector General of the U.S. Department of Health and Human Services (HHS), underscored the importance of compliance in Medicare Advantage plans, emphasizing the risk of fraud, waste, and abuse.
Grimm highlighted managed care risks that the Office of Inspector General (OIG) has identified in their investigations, including upcoding, stinting, and misrepresentation of data. These risks can have significant impacts and cost Medicare millions of dollars. While risk adjustment is critical to the success of Medicare Advantage, the OIG has identified significant problems with risk adjustment, making it essential for plans to prioritize compliance and risk management.
In this new era of value-based care, compliance programs and initiatives must be structured carefully to mitigate the risks of falling short. Organizations seeking to create or participate in value-based care initiatives must be aware of potential regulatory challenges and work to ensure that their compliance programs are robust and effective.
Health plans, in particular, are under pressure to improve documentation and disease management to avoid financial loss. Plans need to be aware of inadequate documentation and the risks that may ensue. Plans might consider moving the risk downside, putting a lot of pressure on providers.
Persivia’s Pop Health Cloud, CareSpace®, is a technology solution that can help providers and health plans navigate the new landscape of value-based care. Persivia CareSpace® works harmoniously with the Persivia Data Cloud to aggregate, normalize, and manage patient data across hundreds of sources. The solution uses machine learning, eMPI, and natural language processing to build dynamic longitudinal patient records, which are processed in an AI engine to generate insights, care gaps, and alerts.
The longitudinal patient record presents the true patient picture by properly documenting patient conditions, risk scores, services etc All this actionable information is presented to providers at the point of care in real-time, enabling them to make informed decisions at the point of care.
The bi-directional data flow allows for linking test results, analysis, or any other steps providers take for disease management directly to the patient records without any mismatch or errors. This helps meet documentation compliance, reduces the cognitive burden on physicians, and improves the quality of care patients receive.
In conclusion, the emergence of value-based care initiatives and the new compliance and audit rules by CMS to make VBC contracts truly valuable are transforming the U.S. healthcare system. Those prepared to adapt to these changes will be better positioned to succeed. By investing in technology solutions like Persivia’s CareSpace®, providers, and health plans can ensure they are well equipped to thrive in the new era of value-based care.