Reimbursement for healthcare management is undergoing massive transformation to a digitally-based, AI-assisted structure referred to as fee-for-value. Provider organizations are accountable for the outcomes they produce and reimbursement is directly tied to performance. The incentives are now in alignment, but providers need the tools and technology to meet this challenge for the financial health of their organizations and the health of their patient populations.

While value-based care has long been a sought-after goal, the technology that enables the insights needed to deliver on this principle have lagged behind. Until now.
BettrAi, with its advanced AI features and cloud-based engineering, offers a fully integrated platform that is automated, transparent, configurable and flexible, allowing healthcare organizations to capture maximum reimbursement and achieve optimal health outcomes simultaneously.

High-performing healthcare organizations who are to successfully transition into the new digital healthcare ecosystem and value-based reimbursement structures must have the analytic capabilities to continually monitor, evaluate, and adjust. Their approach to care management must:

  • foster the efficient, timely, and appropriate use of resources,
  • encourage the full application of evidence-based care management protocols,
  • promote adherence to quality standards, eliminate or minimize gaps in care plan execution,
  • merge and coordinate previously siloed components of care management,
  • enable robust patient engagement,
  • reduce the risk and occurrence of adverse events, along with the need for high-cost
    interventions such as emergency room visits, hospitalizations, and readmissions, and
  • ultimately achieve optimal health outcomes – at the individual and population cohort levels.

The revenue that provider organizations receive is tied directly to the degree to which they perform all the tasks associated with specific types/levels of care management. The BettrAi platform has been designed to automate and make transparent, in real time, the tracking of performance indicators, thus providing the opportunity to keep care plans on track and importantly, institute corrective measures where needed to bring performance up to its fullest potential. This ultimately determines the degree to which revenue is optimized.

Care Management meets Reimbursement. An example illustrates: Transitional Care Management (TCM)

The immediate, transitional post-hospital period of 30 days is critical to achieving the fullest possible recovery and, at the same time, is most vulnerable in terms of potential disconnects in care continuity, abrupt health status changes, and risk of rehospitalization. The CPT codes associated with TCM delineate three highly specific, reimbursable tasks that are prescribed to ensure that this phase is tightly managed.

Task 1: contact is to be made between provider and patient within the first two days of hospital discharge.

Task 2: face-to-face contact is to be made between provider and patient during the 7-14 day post-discharge time frame.

Task 3: a medical determination is to be made by the end of the 30 day period, indicating what the next level of management should be (Principal Care Management or PCM, for example) based on the patient’s condition.

The BettrAi platform allows the supervising administrator or clinician to view precisely which TCM tasks have been completed – at the individual patient level and organization-wide – in real time, at any given point in the month. Through visually powerful graphs and other customizable graphics BettrAi’s dashboards make actionable information easily and immediately accessible.

“Practice compliance scores” are instantly visible, indicating percentage to goal at any given point and time remaining to fully execute. To the extent that tasks have been completed, the organization will be compensated at the designated level for each; should tasks be incomplete, the real-time visualization means that there is time to take corrective measures and see that the full complement of interventions takes place and the maximum reimbursement is attained.

Earlier prototypes of digital healthcare management platforms did not have the capability that BettrAi affords because they only allowed retrospective reviews of performance, thereby eliminating the potential to shore up performance and thereby maximize reimbursement. Instead, BettrAi now offers the win-win-win solution that lowers overall costs by reducing preventable morbidity and resource consumption, maximizes reimbursement for care management “done right,” and optimizes the health status of patients and populations.