Know the Potential ROI
With inpatient CDI and DRG-based payments, there’s a more
immediate and apparent return on investment. With outpatient
CDI, the return on investment will differ depending on the type
of ACO or value-based contract. It may also take at least a year
to fully reap financial rewards.
Still, the C-suite will want to understand the potential financial
impact of outpatient CDI efforts. Use a hypothetical example,
similar to the one displayed in Figure 2 on page 28, that demonstrates how specified HCCs can greatly affect the Medicare Advantage per member per month payment. Combine this data
with how much it costs to care for the patient, and it becomes apparent that without coding any chronic conditions organizations
actually lose money under these types of risk-adjusted contracts.
Present the C-suite with these other benefits of outpatient CDI:
Appropriate physician payments under MIPS.
Beginning this year, cost data counts toward each physician’s
MIPS final score. HCCs help justify why costs may be
higher to care for certain patients.
Improved 30-day mortality metrics. As CDI programs
focus on inpatient clinical validation, they may notice a
decrease in their expected mortality rate. HCC and condition category capture in the outpatient setting can help
offset this decrease. Ideally, the expected mortality rate
will be noticeably higher than the actual mortality rate.
When the gap between the two begins to close, HCCs may
be able to widen it.
More streamlined revenue cycle processes across multiple settings. As lines of communication open between
inpatient and outpatient settings, operational silos begin
to fade. This can lead to greater efficiency overall.
Potential for better outcomes and lower costs. HCC capture is all about population health management—
managing chronic conditions that could otherwise lead to costly
Use Facility-specific Data to Build Your Case
Baseline metrics are critical for any CDI program because they
help demonstrate the need for outpatient CDI, and they’ll serve
as a point of comparison as efforts get underway. Medicare Ad-
vantage plans may be able to provide organizations with HCC
capture rates. However, organizations must keep in mind that this
data may not be completely accurate, or it may even be falsely
elevated if documentation doesn’t clinically support the HCCs.
For the most accurate baseline data, organizations should
analyze their 837 or UB claims data to identify current HCC cap-
ture. If an organization doesn’t have an internal data analytics
team that’s able to do this, it may want to consider working with
a consultant. The following are several questions to consider
when analyzing the claims data:
1. What patient population is included in the advanced al-
ternative payment model in which we’re participating?
How to Obtain C-suite Buy-in
for Outpatient CDI Programs
Optimizing Your Rightful Reimbursements
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