Value-based care is a way to pay doctors based on how well patients get better, the quality of care, and costs. Instead of paying for each visit or procedure like before, providers get paid when they meet certain health goals, reduce hospital visits, or manage diseases well.
For example, if a patient has diabetes, a doctor might get paid based on how well the patient’s blood sugar is controlled, not just how many times the patient visits or gets tests done. The aim is to help patients stay healthier while keeping costs down.
According to the American Medical Association (AMA), almost 60% of U.S. doctors now work in groups that use value-based care models. This means care now focuses more on ongoing health for groups of people instead of just individual visits.
Value-based care creates new rules for how medical billing works, which are very different from old volume-based billing. Medical offices need to think about these things:
In value-based care, coding must be very accurate. CPT codes are still used to record medical services, but now they need more detail. These codes help track patients, measure health results, and support telehealth services.
The AMA says CPT codes are important for:
It’s important for coding teams to stay updated on CPT, ICD-10-CM, and special modifiers that show participation in value-based programs.
Unlike the old way, value-based care often uses bundled payments. This means a single fixed amount covers an entire treatment period. Doctors must work together to stay within this budget and keep patients healthy.
Shared savings programs also exist. Providers can share money saved by giving good care for less than expected, if quality goals are met.
Billing under these systems needs clear records of what services are included and must avoid “unbundling.” Unbundling happens when services that should be billed together are billed separately. This can cause problems like claim denials or accusations of fraud.
Payments depend on reports about care quality. Programs like MIPS, APMs, HEDIS, and MACRA all need accurate and timely data. This puts more work on billing and admin teams to collect and send this information.
If these reports are late or wrong, providers may get less money or penalties.
Medical billing under value-based care is more complicated. Providers must watch performance, manage contracts, and join quality improvement efforts. Smaller offices often find this harder because their staff needs more skills.
Dr. Bryan N. Batson, CEO of the Hattiesburg Clinic, highlights how using doctor leadership and technology can help manage these challenges. His clinic showed better quality results and better use of electronic health records.
Primary care doctors manage the health of many patients in value-based care. Still, they face some problems:
Many doctors feel stuck because most payments still come from fee-for-service. Some say the quality rules do not always match patient needs and take time away from care.
Experts say more upfront payments, less paperwork, better data sharing, and training new staff are ways to help doctors take part in value-based care.
Ambulatory Surgery Centers (ASCs) fit well in value-based care. About 60% of healthcare payments tied to value-based care now involve ASCs. They provide low-cost outpatient surgeries.
Data from CMS shows these programs helped reduce hospital readmissions by 4% over eight years and ER visits by 15%. ASCs help by focusing on prevention, patient education, and cutting unnecessary procedures.
ASCs must collect accurate data and train staff to meet reporting rules. New EHR tools like CareTracker help by automating reporting and improving team coordination.
AI and automation are changing medical billing by handling the complex and large amount of data needed for value-based care.
Simbo AI offers AI tools that help with phone calls and patient communications. This lowers office work and improves patient access, which also supports value-based care goals by helping care teams work better together.
Switching to value-based care billing needs strong IT systems. Medical offices need electronic health records (EHR) that work well with data analysis and billing platforms. These systems must also follow new rules.
The AMA says clear communication and sharing data between payers and providers is very important. Without good data exchange and electronic records, billing teams will have trouble tracking performance and getting the right payments.
Healthcare leaders like Dr. Maria Ansari, CEO of The Permanente Medical Group, say managing patient health depends a lot on good technology and digital tools.
As healthcare moves to value-based care, medical billing must change too. Providers will need very accurate coding, detailed quality reports, and good data management. AI and automation will help reduce paperwork and improve billing accuracy.
Offices that invest in training, IT systems, and good relationships with payers will be better prepared. Medical billing services that know value-based care will become important partners. They will help providers handle payment changes and make sure money matches the quality of care given.
Practice administrators, owners, and IT managers should learn about these changes and use tools and methods that fit value-based care. This will help keep finances stable and support better patient health.
Value-based care shifts billing from quantity of services to quality and effectiveness of care, linking reimbursement to patient outcomes rather than service volume.
Changes include precise CPT coding, outcome prioritization, increased reporting requirements, enhanced care coordination, billing for bundled services, and understanding shared savings structures.
CPT coding is critical for accurately documenting services provided, ensuring that providers receive appropriate reimbursement under value-based payment models.
Bundled payments are a fixed price for a specific care period covering a procedure and its associated services, incentivizing coordinated care and efficiency.
Shared savings models involve providers sharing financial savings achieved through improved patient outcomes and cost-effective care delivery.
In a quality-focused model, billing relies on documented patient outcomes rather than the number of services performed, emphasizing continuous care coordination.
Challenges include adapting to increased reporting, mastering new billing strategies, ensuring accurate documentation, and understanding evolving payment models.
Medical billing services can provide expertise in adapting billing strategies, ensuring compliance with new payment structures, and enhancing coding accuracy, freeing providers to focus on patient care.
Unbundling involves billing separate procedures that should be combined under one code, leading to inflated costs and potential overpayments by payers, considered fraudulent practice.
Care coordination optimizes communication among clinicians, improving the overall quality of care delivered, which is essential for achieving quality-based reimbursement.
Simbo is using AI agents to automate all phone related workflows. Connect now to know more.
Schedule AI Agents Demo Now© Since 2019, Simbo AI.
