Part 6 of 12 – Multiply Revenue by Being a Leader in Value-Based Care – Here is How

Value-Based Care

12 Part Series: MedCV Practice Financial Management – Insights & Tips You Need to Know About to Quickly Maximize Your Income

Tip 6 of 12 – Offer value or risk losing money! CMS offers incentives you need to take advantage of!

Focus on Value Based Care and Population Health:
a. Assessment: In recent years CMS has recognized the need to focus on preventing periods of acute illness as well as promoting health and wellness.  As a result, they have added payments for services that support these objectives.  One such service is the annual wellness visit (AWV) which is intended to update the provider on the patient’s health history and lead to a personalized prevention plan.  Next, the chronic care management (CCM) code enables providers to bill for continuing support services outside of the face to face visit for patients with multiple chronic conditions.  These CCM claims must be properly documented with time and services provided.  Transitional care management (TCM) is a third service promoted by CMS involving physician follow-up with patients post hospital discharge.  These follow-up calls and visits are intended to prevent gaps in care and reduce the probability of readmissions for the same illness.  CMS also pays for remote Patient Monitoring (RPM) services.  This service focuses on patients with chronic conditions such as COPD, heart failure, or diabetes and is intended to prevent periods of high acuity as well as increase the capacity of the physicians’ medical team.  The reduced periods of high acuity will also result in a reduction in emergency visits and hospital admissions.

The opportunity for each of these codes can be assessed as follows:

  • AWV: This value is projected by totaling the number of Medicare patients on your primary care panels and multiplying that total by the average reimbursement.  The CPT codes are G0438 (initial) and G0439 (subsequent) and the average reimbursement is $132.
  • CCM: To project this annual value identify the total number of Medicare patients with two or more chronic conditions on your primary care panels.  Then multiply that number by the average reimbursement per month and multiply the result by 12.   The CPT code is 99490 and the average reimbursement is $42, assuming the patient services for each patient consume 20 minutes per month.
  • TCM: Use historical data to identify the number of annual hospital discharges for Medicare patients on your physician panels. Multiple this number by the TCM reimbursement rate.  CPT code 99495, at a reimbursement of $175, is charged on moderately complex patients if contacted within two days of discharge and a face-to-face occurs within 14 days.  CPT code 99496, at a reimbursement of $237, is charged on highly complex patients if contacted within two days of discharge and a face-to-face occurs within 7 days.
  • RPM:  Four CPT codes apply to this service. The first code, 99453, is for the equipment set-up and patient education.  CMS pays $19 for this one-time service.  Next, code 99454 is for the equipment and daily monitoring.  The CMS rate for this service is $64 every thirty days of use.  The intervention and treatment services resulting from the RPM pays $51 for the first 20 minutes and $42 for each additional 20 minutes each month.  These services are assigned codes 99457 and 99458, respectively.  Your revenue potential from this opportunity can be projected by working with your physicians to identify the patients who will benefit from this service and then applying the above reimbursement rates to the resulting volumes.

b. Improvement Action: Physician education is a foundational step toward pursuing the population health opportunities.  Assigning a physician population health champion who leads by example is also essential.  Next, the process of care must be clearly identified for each of the four services with key access points established and required actions defined to initiate these services. 

Quantifying the opportunity at the provider level and instituting population health performance factors in the compensation system will also help improve participation.   While some organizations may find the above steps sufficient to institute these population health services, others will find the need for additional support to accomplish their population health goals.

Fortunately, several vendors offer software and support services that reduce the effort required of the provider to accomplish these services.  Some vendors provide no risk contracts with their fees established as a percent of the additional revenue generated by the service.

AllHealthCHOICE is a vendor that offers a no risk arrangement for its remote monitoring solution, branded as MyCharlie.   Those using MyCharlie have recognized a 52% reduction in readmissions and a 75% reduction in emergency visits.  To learn more about MyCharlie remote patient monitoring we encourage you to learn more on their MedCV Teaming Partner page and to connect with John Roddy at AllHealthCHOICE.

John Roddy
All Health CHOICE

Like we like to remind our physician members at the end of each of these 12 part series, as a physician, if this sounds like a lot of work and maybe even has your “business anxiety level” up a few notches, you are not alone. The great news is that your role in this should just be to make sure it gets done and that those who are going to be responsible and accountable for this can explain and report details about what the plan looks like and its status to you.

Share this article with your practice manager, group administration, or hospital administration to make sure they are working on this or see what resources they have to get at this work. If they need help in getting started, they should consider connecting with John Rezen at Value Health. The key is to be able to have your baseline, you would expect your team to report to you the improvement(s) made and the results.

Stay tuned for Part 7 of 12, Staffing minutes per encounter next week as we move into the last of the 6 part series focused on Expense Management. If you can’t wait that long, no problem, just contact John for the full 12 part series. Again, it’s in your best financial interest to make sure each of these 12 Key Performance Indicators are optimized, you understand them, and take action, even if the action you take is to share the series and your new found business insight with your group or hospital administration.

John Rezen

President & CEO
Value Health, LLC

MedCV Advisory Board Member

Financial Improvement

Each of the 12 part “2-3 minute reads” in this Financial Improvement series provided by John Rezen, FACHE, MHA and your MedCV team can quickly add CASH to your bottom line just by having your practice “work smarter” for you. Even if you are not directly responsible for the management of your practice, knowing this information will help you make sure you are making the income you deserve.

As hospitals and medical groups emerge from the COVID- 19 economic shutdown, they will be faced with significant pressure to improve their financial performance. The following checklist of performance measures should help physician enterprises identify financial opportunities and accelerate their improvements. Below are the 12 topics, to read a previous segment, click on the name/link. The current segment is Blue and upcoming segments are Black.


  1. Staffing minutes per encounter
  2. Average staff pay rate per hour
  3. Providers’ pay per wRVU
  4. Service costs-to-revenue
  5. Supply and drug costs-to-revenue
  6. Overhead costs-to-revenue

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MedCV Top Teaming Partners

Published by Niels Andersen

Founder and CEO of KontactIntelligence, MedCV, VetCV, and VeritasHealthCare. 40 Years in healthcare, 20 years in healthcare tech supporting Government and commercial health systems, physicians, as well as Veterans and their families throughout the US.

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