Yes, You Have What It Takes To Lead Your Practice And Your Profession

by  Kem Tolliver, CMPE, CPC, CMOM
Sep 20th, 2022

If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.

Lead where you stand. No matter what your position is, you can lead. A Phlebotomist can lead by providing patients with the necessary instructions and information to put their minds at ease prior to bloodwork. In instances when billers need to explain a claim during the insurance appeal process, they are leading the adjudication process for payment. There are times when coders must explain correct coding initiatives to provide compliance and reimbursement education to healthcare practitioners.

With all the opportunities to lead in healthcare, we also need to stay informed on initiatives that will not only impact our organizations, but also the industry, as well as our respective professions. Our front office staff - who are responsible for pre-visit services and patient financial verification - need to remain up to date with insurance reimbursement guidelines to notify patients of their eligibility, benefits and out of pocket expenses. Those of us who provide clinical care must remain up to date on patient care initiatives that improve quality reporting and treatment outcomes. Certified coders are the gatekeepers of ICD-10-CM, CPT and HCPCS guidelines and modifications – which requires attention to detail and access to real-time coding resources.

There is so much information available to us. It can be daunting to identify or even select our resources. This is where the rubber hits the road. Using sources that are not credible adds vulnerability and risk to our organizational compliance. Doing so also diminishes our standing as 
Subject Matter Experts (SMEs) within our practices. There are so many people who rely on us for accurate information, we don’t want to disappoint them with the wrong answers. 

As important as it is to get it right, it’s also incumbent upon us to remember that each person on our team is human. With that being said - can we normalize being human? Not having everything figured out. Not having all the answers but knowing where to get them. The more grace and understanding we show to others, the more we can expect it in return.

We have humans, leading from where they stand, and relying on credible resources. How do we excel? We start by understanding what the healthcare landscape looked like, where it is today, and what it will look like tomorrow. Later this year, CMS will publish the 2023 Final Rule. Included within the Final Rule will be guidance on the CY 2023 Medicare Physician Fee Schedule (MPFS). Several significant changes to be on the look-out for include:

CMS MPFS 2023 Proposed Rule

• Decrease to the Conversion Factor (current proposal is $33.08)
• Adoption of CY 2021 PFS final rule for office/out-patient E/M visit coding and documentation guidelines for other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services and cognitive impairment assessment)
• Split (or Shared) Visits – Substantive Portion definition delay
• Extension of telehealth flexibilities for 151 days following the end of the Public Health Emergency
• Regulatory revisions to reduce existing barriers to Behavioral Health Professionals
• Add COVID-19 vaccine and its administration under the Part B vaccine benefit

There are many regulatory, documentation, and reimbursement guidelines to stay up to date with these days. Although the above is not an exhaustive list, it demonstrates the significance of changes that are coming down the road.

Check here for additional information on the Proposed Rule:

https://cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

Many of us reminisce on the good old, “Fee for Service”, days – when CMS and commercial insurances paid healthcare practitioners based on an allowable amount, which included being paid for the “fee for the service” that was provided. The volume-based fee for service payment model has been replaced with, “Value Based Payment Programs,” and “Hierarchical Condition Categories.” The need to demonstrate improved health outcomes has been integrated into reimbursement using models such as:

1. Merit-Based Incentive Payment System (MIPS)
2. Alternative Payment Model (APM)
3. Risk Adjustment Factors (RAF)

Value Based Payment Programs - Performance Year (PY) 2022

To improve prior and future population health outcomes, value-based payment programs were introduced not only as a way to share financial risk but also financially incentivize practitioners for the quality of the care provided to beneficiaries. This payment reform has a Quadruple Aim of:

1. Improved care for individuals
2. Improved care for populations
3. Decrease healthcare costs and expenditures
4. Improve the well-being of care teams

These payment structures focus on risk and incentives, and fee-for-service payments have not entirely gone away. Throughout the performance period FFS is paid and at the end of the performance period, payers will adjust payments (via a bonus or penalty) based on reported measures. All this boils down to the healthcare system remaining sustainable; to fund itself long-term.

Risk Adjustment Factor (RAF) is the payment model that relies on forecasting healthcare expenditures. Medicare Advantage Plans, other funding sources and Integrated Healthcare models such as Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) rely on RAF to project the cost of care. Many healthcare organizations have joined forces to provide coordinated care. These care models work to ensure that patients have access to the right care at the right time, while keeping other practitioners informed and avoiding unnecessary services and medical errors. 

These projections are based upon reported ICD-10-CM codes. The goal for RAF is to accurately demonstrate complexity of a beneficiary and of populations. When inaccurate documentation and code selection paints the wrong picture, the wrong cost/payment is projected.

Demonstrate complexity to justify Risk Adjustment Factor (RAF) & Payments

• Lower acuity = Lower Reimbursement Forecast
• Higher acuity = Higher Reimbursement Forecast

Certified coders are an integral component of RAF and accuracy of payments. We can lead our organizations by ensuring documentation supports complexity, Medical Decision Making (MDM) clearly demonstrates risk, and reported ICD-10-CM provides necessary specificity. Coders lead in reimbursement by educating practitioners on Clinical Documentation Improvement (CDI) to demonstrate acuity for accurate payment for Fee for Service and Risk Adjustment Factors.

We can excel at being leaders where we stand by becoming a go-to-person. Consider your strengths and use them to lead your team members. Let everyone know what you’re good at; what you enjoy doing, so you create your own niche within your organization. Build on the strengths and weaknesses of your team members. Here are a few additional considerations to take your leadership up a notch:

• Become a member of a healthcare organization (PMI, AAPC, AHIMA, HIMSS, MGMA)
• Consider obtaining a certification
• Volunteer on a healthcare organization’s committee
• Write an article for a healthcare organization
• Create internal “How To” documents for your organization
• Speak up in staff meetings – create agenda items
• Become a mentor and/or find a career mentor

This is also a great opportunity for us to get ahead of innovations and lead by streamlining workflows. We can achieve this by automating repetitive workflows and using electronic resources to cross-check code selections.

Take this call to action as your motivation to not only lead within your organization but lead in your profession by implementing four leadership cornerstones:

1. Protect – Yourself and your organization by mitigating risks
2. Guide – Your practitioners and your team with your expertise
3. Mentor – Others so your knowledge is shared for the greater good
4. Educate – Using trusted resources and training tools that work for your team