Implementing Common Ground among Next Generation Reimbursement and Quality Systems [Sponsored]

This article is published in sponsorship with Elsevier, and is an excerpt from a white paper by John Glatthorn, practice director at Optera Healthcare Strategies. Download the white paper here.

We may look back on the 25-year span following the change of the millennium as one of the most densely populated periods of healthcare regulation ever seen in the history of the United States. Every year, individual clinicians, private practices, and health systems are bombarded with new coding, compliance, quality, and reimbursement models, making staying ahead of the curve in terms of overall strategy nearly impossible. Executives, physicians, and healthcare experts would probably agree that it is impossible to maintain a status quo level of performance if your strategy is one of pure reaction to each new deadline that rears its head from the Department of Health and Human Services.

Although we all agree that this is not an ideal way to approach the onslaught of rules and penalties that will inevitably change our healthcare business forever, this siloed and reactive thought process is by far the most commonly implemented strategy (or lack of one) in the marketplace today. For many institutions, ICD-10 was the first significant foray into a highly structured, project management-oriented transition plan that encompassed almost all the healthcare provider and administrative disciplines into one unified approach. Enterprise electronic health record (EHR) implementations have done this for the information technology and clinical worlds but one might argue that these projects rarely included health information management (HIM), revenue/reimbursement, and CDI professionals as equals or even key players.

ICD-10 presented three large and diverse challenges:

  1. It was so big that its change had an impact on almost every function of a health system
  2. The specificity offered called into question the sacredness of physician discretion over depth of diagnosis
  3. It made clinical documentation completeness and coding accuracy the cornerstone for all future healthcare reimbursement and quality strategies

Some of the earliest lectures and briefings on the subject back in 2010-2011 made a point of stating that “this is not just an IT problem or a coding problem.”1 This is because when we as healthcare professionals are confronted with problems that shake our very foundation, we must look to more innovative and structured methods of problem solving that transcend departments and business units. We must create a more unified approach to managing our changing clinical, regulatory, and revenue cycle environment. Creating a strategy begins and ends with understanding the problem you wish to solve and creating goals you wish to achieve.

The problem with government mandates and blindly issued regulations is that they create a sea of acronyms fostering confusion, contradiction, and—most importantly to our success—poor communication resulting in poor planning. Applying those same problem solving principles to next generation healthcare is certainly daunting, but not impossible. The first step in this journey is to ask the correct questions about these new regulations. To use a cooking analogy, we must determine if they are all made from the same ingredients, and do they share a common cooking philosophy? On the surface, initiatives like ICD-10, IPPS/DRGs, HACs, RACs, HCCs, MIPS, and ACOs seem distinct, but we will soon find that they share a common language. Each was instituted by the government with a common set of problems and goals.

Download the full white paper at to read more about the Next Generation Reimbursement Philosophy and The 5 Pillars, an arbitrary collection of healthcare concepts derived from the collective regulation of the past 10 years, and how organizations can implement these “rules” to build their analysis and education toolkit in a unified fashion to get better results.

Are you attending the AHIMA conference in Baltimore, MD from October 15-19? Be sure to visit Elsevier at booth #413 to pick up a copy of the full white paper and learn more about our education and eLearning solutions for coding, CDI, compliance, and reimbursement.

Elsevier offers education solutions designed to help healthcare organizations optimize staff performance and data quality for value-based programs and financial health. Through education and training, staff can be confident in their coding and data abstraction skills, and be empowered to help obtain appropriate reimbursement, reduce risk, and improve performance.

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