How Value-Based Care Models Are Impacting Billing Practices

Strategies Providers Can Implement To Succeed In This New Reimbursement Landscape

By Isaac Smith, Billing/coding/reimbursement specialist, Medcare MSO
LinkedIn: Isaac Smith
LinkedIn: Medcare MSO

Medical billing is a field that is constantly evolving, with new updates and developments. One such development is value-based care, which is currently transforming the medical billing industry. Value-based care is a provider payment model that prioritizes high-quality healthcare over the quantity of services. The goal of this payment model is to provide better care to patients while reducing the cost of care.

This article is a guide on value-based care models, what they are, how they impact billing practices, and what strategies should be adopted to succeed in this new reimbursement landscape.

So, without any further ado, let’s dive into the details of value-based care models:

Understanding the Basics of Value-Based Care Model

According to the Centers for Medicare and Medicaid Services (CMS), value-based care is a model that provides cost-effective, high-quality care while improving patient satisfaction and outcomes.

The Centers for Medicare & Medicaid Services (CMS) have introduced a variety of value-based care models, including:

  • Medicare Shared Savings Program,
  • Next Generation ACO Model,
  • and Pioneer Accountable Care Organization (ACO) Model.

Other important value-based care models that are revolutionizing the medical billing industry include the capitation payment model, patient-centered medical homes, bundled payments, and pay-for-performance Private payers have also followed suit, adopting similar accountable, value-based care models.


A network of hospitals, physicians, and other providers coordinate to provide quality care

It eliminates redundant care and focuses on disease prevention

The level of risk is dependent upon the selected agreement, which ranges from no downside to high downside

The reimbursement rate goes up based on metric performance

Bundled Payments

A single payment method that reimburses multiple providers who coordinate during a single episode of care

Used in CMS programs such as

There is a high level of risk for providers if sufficient care isn’t provided

If providers can reduce the cost of their services below the price of bundled payments, they can pocket the savings.

Patient-Centered Medical Homes

It is linked to better chronic disease management

A team of physicians manages the primary care of patients to increase coordination and quality

Patient-Centered Medical Homes have a high-reward ratio for providers based on performances

It is graded based on metrics like appropriate use of services, patient access, and engagement

A variety of quality metrics are used to calculate value-based reimbursements, along with population health overall. In contrast to the traditional model, value-based care is data-driven. Providers need to report to payers on specific metrics, which makes medical billing a burdensome task.

Let’s discuss how value-based care impacts medical billing.

The Impact of Value-Based Care on Medical Billing

Implementing value-based care brings several changes to medical billing services for clinicians. These changes include:

  1. Emphasis on Outcomes:
    Value-based care focuses on the quality of services rather than the quantity of services. Providers must accurately track and report patient outcomes to receive the maximum reimbursement rates.
  2. Additional Reporting Requirements:
    Value-based care requires physicians to participate in alternative models and report on specific quality measures. The billing process becomes complex as there is additional documentation and reporting required.
  3. Care Coordination:
    Value-based care requires coordination among a network of physicians, hospitals, and other providers. This communication is necessary to deliver better care to the patients but it can make the billing process nerve-racking.
  4. Shared Savings Models:
    Some value-based care programs employ shared savings models. In these models, healthcare providers share in the financial savings generated by improved patient outcomes. Physicians must become acquainted with these models and comprehend how they affect their reimbursement.

Value-Based Care Strategies for Providers to Succeed

Shifting to a value-based care model may seem overwhelming to providers, but with the right strategies and analytics, you can make the transition smoothly. Here are the top 3 strategies that you need to adopt while shifting to the value-based care model:

1. Identify Patients with the Highest Risk
The first and most important strategy in shifting to value-based care is having an advanced EMR that can help you identify where there is a gap in the care. Modern analytics software can transform your data into actionable insights. It provides you with detailed reports and identifies high-risk populations so that you can make informed decisions.

Healthcare analytics software can provide you with the following high-risk patient profile data;

  • Electronic Health Records (EHRs)
  • Health risk assessments
  • Patient demographics
  • Claims data
  • And Clinical risk scores

Providers can analyze, integrate, and process this data to discover the patients who face the highest risks. Collecting and assembling this data will allow providers to make evidence-based decisions, which will boost their revenue growth.

2. Maintain Good Relations with Other Provider Representatives
Maintaining good communication with the other providers is essential so that you can navigate the different requirements of each payer. You need to be aware of the quality checks and the criteria of the bonuses to achieve the highest possible reimbursements.

An open communication policy allows you to proactively resolve disputes and remain ahead of the curve in value-based care arrangements.

3. Outsource Your Medical Billing Services
Value-based care often comes with additional reporting requirements. Outsourcing billing can alleviate this burden by ensuring that all necessary data is captured and reported accurately. This frees up providers and their staff to focus on core clinical tasks.

They have an expert coding and billing team that ensures accurate coding and timely claim submission, maximizing reimbursements from insurance companies.

The Bottom Line

Value-based care models focus on patient care. These models assess how providers can improve the quality of care based on specific measures such as using certified health IT, reducing hospital readmissions, and improving preventive care. Based on performance, providers can get the highest payments from commercial and government payers. However, they need to be vigilant and proactive in their medical billing process so that there are no errors that could lead to penalties.

And for that, they can implement these 3 strategies that will improve their value-based care, ultimately improving their revenue growth.