Critical Questions for Value-based Programs

7 Questions CFOs Should Ask Value-based Programs Managers

Thinning margins means that it’s more important than ever to make sure your organization is capturing every dollar earned. Now that the Quality Payment Program is here, it is imperative that CFOs have their sights squarely focused on these programs with the ability to predict the associated financial risks. Don’t be surprised by program penalties.

1. Have we documented the financial pros and cons of submitting our eligible provider data by the individual or GPRO method, and what were the results? If the administrative task of taking this step is too laborious, what are the financial pros and cons of hiring someone to do it for us?

Your method of submission can have a big impact. We recommend thoroughly evaluating the pros and cons of method selection well in advance of the deadline. Organizations specializing in managing the Quality Payment Program can guide you to the optimal method and measures and can help you take steps to ensure that you receive the highest possible quality score.

2. Do we understand the financial impact of our measure selection?

If you’re not comparing the measures you want to submit against the benchmark data by submission method, you could run a serious risk of landing below the performance threshold, which means penalties against the organization. Just because it looks like your organization’s scores for each measure you’ve selected are high, compared to the entire population, they may not be good enough to land you above the performance threshold, especially as it is re-evaluated every year. There’s no reason not to compare them before submission as a means of predicting your final performance. Unfortunately, some vendors don’t provide this level of analysis, so it’s a good question to ask before selecting a vendor to help you.

Also, keep in mind that individual clinician performance will be posted to the CMS Physician Compare website as well as shared with consumer sites like Yelp, Angie’s List and others and this could have further financial impact on the organization when the public begins to make choices about care based on this information.

3. Do we have documented processes and procedures related to audit planning?

In 2014, more than 10,000 audits targeted eligible providers and the failure rate was around 22%. Simply missing a single piece of audit documentation can mean having to return incentive payments. It can be a sound investment to engage an industry expert to make sure your processes and procedures set you up for audit success.

4. How are we calculating estimated incentives and penalties?

Especially during the incentive period of these programs, some program managers have felt more comfortable underestimating potential incentives to provide a cushion in case something happens. Now that we are moving into the penalty phase of the Medicare program, the economic risk is even more important to estimate and understand.

5. How many of our eligible providers received a penalty letter last year? What was the total sum of those combined penalties?

The 2017 penalties can be a 4% reduction in Medicare reimbursement and those penalties increase up to 9% for the 2020 performance year. 

6. How often are we meeting as an organization throughout the year to review our goals and estimated economic risk?

Be proactive. Our most successful clients have multi-disciplinary teams that include C-level and VP-level executives meeting at least monthly to review performance and estimated incentives and penalties and to develop action plans for immediate intervention.

7. Do our value-based program managers feel that they have the resources, educational opportunities, and organizational support they need for our facility to be most successful in these programs? In other words, do we have a program management effort in place that is proactive, adaptable, and capable of working through change in people, processes, and technologies as these programs continue to evolve?

It’s imperative to have a support system and a backup plan. Without it, the organization may suffer if much has been invested in a limited number of resources (or a single resource).