Value-based care models are taking over the healthcare industry at a fast pace, with health systems and authorities changing policies and goals to keep up with it. However, for the complete actualization of the value-based care model in a practical scenario, health systems will have to depend on advanced technologies to ensure minimal room for error. AI in healthcare is also developing quickly, with health technology companies coming up with evolved automated solutions to support the provider organizations.

HCC or Hierarchical Condition Category coding is one of the most crucial determining factors of the change from volume to value-based care. But it comes with its own set of complications, which is burdensome for the provider organizations without a large in-house team. Specific solutions from AI in healthcare can help overcome these hurdles and accelerate your journey towards the goal of value-based care. This article will discuss the issues with transitioning to value-based care, the complexities of coding, particularly HCC, and how you can address these issues with the help of AI in healthcare.

Transition to Value-based Care

  • Shifting to value-based care has picked up pace in the last year, and every provider organization is trying to keep up with the change.
  • From the enrollment point of view, the increase in the number of Medicare Advantage Plans indicates how the health systems are switching to value-based care.
  • According to a recent survey from the Kaiser Family Foundation, the number of Medicare Advantage beneficiaries will increase to over 40% by 2028.
  • However, shifting to value-based care becomes highly complex since multiple billing and coding challenges crop up at every turn.
  • CMS has published the HCC coding system along with the Risk Adjustment Factor score system to simplify the billing procedure in the new system.
  • But for the implementation of the system and to ensure that the documentation is error-free, healthcare organizations need to upgrade their automation platforms.

Administrative Burden for HCC

  • HCC is a well thought and comprehensive way to add a codified value to healthcare. But it also needs a robust system to make sure that it works properly for the intended purpose.
  • Often healthcare organizations with small billing teams or independent practitioners find that documentation for HCC is a highly complicated affair.
  • Though CMS introduced HCC way back in 2004, the use of this coding system has gone up swiftly in the last few years. Till 2020, there are close to 90 categories of HCC, each associated with different determining factors, taking the total number of unique cases to hundreds and thousands.
  • Every HCC is related to an ICD-10 code in combination with different demographic factors of patients. The extensiveness of the system provides a great boost to billing and coding procedures, both for providers and payer networks.
  • The common issue that most provider systems complain about is the administrative burden associated with the process.
  • If the health system cannot afford to run a massive in-house team with trained professionals, then the road to implementation often becomes rough.
  • Some of the other organizations who can still finance a large team find that a significant amount of investment goes behind maintaining the clerical jobs, making it not very viable for the long run.

Increased Pressure on Physicians

  • Clinicians have a hard time balancing their time and attention between patient interaction and maintaining administrative health records.
  • According to a survey published in the American Medical Association blog in 2018, 32% of the physicians spent more than 20 hours taking care of administrative duties, while 14% of the physicians spent more than 30 hours seeing patients.
  • Many clinics follow the practice of getting the coding charts checked by the physicians to avoid any error in the process.
  • However, this clusters the routine of the providers further. Firstly, the physicians’ schedule gets more difficult to maintain with the repetitive tasks getting layered in the everyday routine.
  • Secondly, they often do not get the time to look at the coding charts and process them immediately. The delay in time costs the reimbursements to slow down and disrupts the revenue cycle management.

CAPD: Solutions from AI in healthcare

Artificial intelligence can resolve many of these issues and take off the burden carried by physicians in their everyday schedules. Computer Assisted Physician Documentation (CAPD) is one of the finest ways to take care of the medical billing challenges in the case of a value-based care model. Here are some of the crucial benefits of having such a system:

  • An advanced automation system such as CAPD works very well in capturing HCC coding systems. This means that you get more accurate HCC codes in a considerably shorter span of time without having to invest a great portion of your staff.
  • You can venture into more risk-based payment plans with the help of this automation platform. The documentation will have minimal to zero errors, thus improving the accuracy of your billing work and increasing the revenue flow.

To know why risk-based payments are slowing down, you can read the article here.

  • The physicians find it easier to juggle both patient care and EHR maintenance for billing and diagnostics. CAPD is capable of combing through numerous medical records and analyze them to give you a proper picture.
  • It also facilitates the transition from reactive to proactive care by identifying high-risk patients beforehand and alerting the physicians.
  • Organizational efficiency gets a massive boost with this system. In a manual setup, most healthcare systems find it overwhelming to process 40 categories of HCC in a single day. On the other hand, CAPD can process 86 categories in the same day with minimized error, if any.
  • CAPD works both for out-patient and acute care patients, making it versatile to use in any medical setup.

We hope this blog helped you understand the complications of the HCC coding system in value-based care and how AI in healthcare can help. If you have any queries or suggestions, please drop a comment below. For more such articles on healthcare billing, management, and technology, please subscribe to our blog. Follow us on LinkedIn, Twitter, Facebook, and Instagram.