MBA FPX 5006 Assessment 1 Billing Policies and Procedures Scoring Guide

MBA FPX 5006 Assessment 1

MBA FPX 5006 Assessment 1

Value-Based Purchasing

Value-based purchasing or payment equals accountable care. It is aimed at reimbursing health care services at more reasonable rates than fee-for-service and focuses on outcomes rather than the activity of health care providers.

This model contrasts the fee-for-service payment model, which rewards facilities and practitioners for performing more work, meaning more payment for more care. The main principle of VBP is the Triple Aim – therefore, patients’ outcomes and satisfaction, simultaneously decreasing the general healthcare expenditure.

In this section, we present the main features and characteristics of VBPs, which are as follows: PointF, The types of payments, are a core component of the VBPs, as they define how value is created, delivered, and expected by the purchaser. Value-based purchasing incorporates several vital elements to achieve its goals:

  1. Performance Measurement: The players are evaluated on results, safety, and satisfaction through several benchmarks, including patient outcomes. These metrics assist in evaluating care quality. Parameters that are applied to assess the quality of care include:
  2. Incentive Payments: These goals ensure efficiency in providing health care and offer financial rewards to providers who attain the stipulated performance standards. On the other hand, providers found to have not met the standards may be liable for the financial consequences.
  3. Transparency: The public is given information regarding the providers’ performance and additional information, which demands accountability from providers; this makes the systems accountable and efficient.

Here, we describe programs that aim to engage in value-based purchasing.

  1. Hospital Value-Based Purchasing (HVBP): This is a federal program administered by CMS that pays bonus amounts to incentivize acute-care hospitals for performance reported on services they offer to Medicare patients. The program assesses hospitals across numerous clinical domains, such as clinical performance, patients’ views, organizational orientation, and productivity.
  2. Skilled Nursing Facility Value-Based Purchasing (SNF VBP): This program also targets SNFs, as does HVBP. It links a percentage of Medicare payments to the quality of care given, especially in reducing readmissions.
  3. Merit-Based Incentive Payment System (MIPS): MIPS is one of the new payment models included in the MACRA legislation. It aims to combine several prior programs and assess physicians according to quality, cost, improvement activities, and information use.

Understanding MACRA

MACRA, enacted in 2015, actually holds the kernel of altering the current Medicare reimbursement model in a way that has not been witnessed before, especially if the key aim of enhancing care quality while simultaneously containing costs is to be considered.

MACRA eliminates the previous SGR formulas to calculate Medicare payments to providers and upgrades the new payment system to feature value-based care.

 Key Components of MACRA

  1.   Quality Payment Program (QPP): MACRA launches the QPP with two primary tracks – MIPS and APMs, where MIPS has two categories: the Christian is eligible for.

MIPS: This pathway combines current Medicare initiatives such as PQRS and the Value Modifier (VM) Program into a unique system. It can obtain additional rewards by assuming more risk while proving the quality of the service provided at a decreased cost.

 Examples of MACRA in Practice

MIPS Implementation: A group of physicians from an extensive healthcare network enhanced their productivity and AMA-PRES quality scores, got maximum Medicare reimbursement by integrating EHRs in their work units, and updated themselves by continuing their professional development.

APMs Impact: ACOs involved in an advanced APM improve care outcomes, decrease the restitution rate, rate,e chronic illnesses, and g, and generate massive performance bonuses.

The present studies highlight the effects of MACRA on prompting providers to shift towards quality provision instead of sheer quantity. In the Journal of the American Medical Association (JAMA), there are early indicators of positive change concerning clinical results and spending for organizations engaged in the QPP.

 Merit-Based Incentive Payment System (MIPS)

  1.   Quality: Contributes to determining the quality of offered cases based on patients’ outcomes and compliance with recommended protocols.
  2.   Cost: Measures the productivity of services using the Medicare employer’s spending on every patient and annual spending per capita.
  3.   Improvement Activities: Promotes participation in practices that enhance patient care, such as care delivery and patient safety.
  4.   Promoting Interoperability: Supports the implementation of EHRs to enhance individual’s health information and support them in receiving proper care.

  Advanced Alternative Payment Models (APMs)

Another track under MACRA’s QPP is Advanced APMs, classified as Advanced Alternative Payment Models. APMs are intended to reward favorable patient outcomes and efficiency by giving more responsibility toward patient costs to providers. Examples of APMs include:

  1. Accountable Care Organizations (ACOs): Entities of doctors, hospitals, and other healthcare organizations formed on a contractual basis to deliver integrated high-standard healthcare to Medicare beneficiaries.
  2. Patient-centered medical Homes (PCMHs) are systems of care delivery that include integrative and sustained first-contact, continuous, individualized patient-physician partnership.

Relationship Between MIPS and APMs

MIPS and APMs are related because both are designed to increase care quality and cost-effectiveness in the framework of QPP. MIPS is available to all providers; however, eligible clinicians can choose to report to advanced APMs if their practice type is appropriate and ready to take on the financial risk. Participants in these advanced APMs do not have to submit MIPS reports and can get extra incentive payments for quality or cost measures.

Recommended Quality Measures for the Clinic

  1. Measure Title: Diabetes: Can Be Identified By Hemoglobin A1c Levels >9% Of Poor Glycemic Control
  • Description: Number of patients aged 18-75 with diabetes with HbA1c > 9%.
  • NQS Domain: Organization of Safe and Efficient Clinical Care
  • Meaningful Measure Area: Chronic illnesses remain a significant health challenge globally and thus require proper management.
  • Primary Measure Standard: The clinical recommendations for diabetes treatment include monitoring and maintaining tbA1c to minimize complications. Every diabetic patient must try to maintain good HbA1c levels to avoid extreme conditions such as neuropathy and retinopathy.
  • Example: One clinic organized a diabetes management regime incorporating the assessment and care of diabetic patients’ HbA1c and patient education, which reduced the number of patients who exhibited poor control overall.
  1. Measure Title: Methods of managing high blood pressure:

Description: Proportion of patients 18-85 years with hypertension who achieved a BP check <140/90 at least once during the measurement period.

MBA FPX 5006 Assessment 1 Billing Policies and Procedures Scoring Guide

  • NQS Domain: Orderly Professional Treatment
  • Meaningful Measure Area: Chronic Disease: Prevention and Control
  • Primary Measure Standard: In light of this, managing blood pressure is crucial to decreasing the prevalence of heart disease and stroke.
  • Example: As part of a clinic’s quality improvement initiative, an EHR was used to record and monitor patients’ blood pressure readings, which helped the clinic achieve better control of hypertension.
  1. Measure Title: A decision was made about the type of colon or rectal cancer screening offered to men and women of a specific age range.
  • Descrrangesn: Proportion of adults (50–75 years) who had appropriate screening for colorectal Cancer.
  • NQS Domain: Community/Population Health
  • Meaningful Measure Area: The 9 Federalist papers laid down the guidelines for the following four categories of preventive care:
  • Primary Measure Standard: Colorectal cancer can be detected through screening, and hence, if people take screening tests often, this reduces their mortality rates because the disease can be treated once detected early.
  • Example: Following up on the patients and reminding them of recommended screenings ultimately helped boost the clinic’s colorectal cancer screening rate by twenty percent.

Justification for Recommended Quality Measures

All the above quality measures proposed depict the clinic’s knack for delivering health care services with a focus on the patient and chips in on resolving common health issues within the patient population group. Thus, focusing on such metrics will result in better clinical benefits, increased patient satisfaction, and efficient reimbursements concerning MACRA’s MIPS and APM tracks.

MBA FPX 5006 Assessment 1

Addressing Chronic Disease Management

Diabetes: HbA1c Poor Control (>9%) and Hypertension: Management of high blood pressure is critical in treating chronic diseases, including those presented by fifty-four participants, which has been linked to high morbidity and mortality.

Studies indicate that better control of diabetes and hypertension leads to decreased incidences of cardiovascular diseases, kidney failure, and hospital admissions, among others, and improves the patient’s health through improved health outcomes, lowering healthcare costs.

For instance, the American Diabetes Association has posited that there is conclusive evidence showing that enhanced CGM drastically reduces the incidences of microvascular complications.

Enhancing Preventive Care

Colorectal Cancer Screening is the identification of asymptomatic colorectal cancer, liable to treat and hence cut down mortality significantly. Screening has been recognized as an effective means of raising awareness of early onset and has helped in keeping a check on cases of late-stage cancer.

Through this measure, the clinic can enhance the delivery of preventive care and hence has the advantage of putting the patient’s health status into a better position in the long run.

Improving Behavioral Health Outcomes

Depression Remission at Twelve Months is related to mental health, while most assessments in primary care lack focus on this aspect. Meta-analyses of studies have also suggested that integrating behavioral health into primary care teams enhances patient outcomes and satisfaction.

Nevertheless, it is crucial to pursue effective treatments for depression as it can also improve the general health state and decrease the patient’s number of other diseases.

If you need complete information about class 5002, click below to view a related sample:
MBA FPX 5002 Assessment 2


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