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Value-Based Care | Care Management

How ThoroughCare Supports Care Management Compliance and Value-based Care Performance

April 30th, 2024 | 11 min. read



Content Team

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Software should make meeting compliance and value-based care contracting requirements seamless. ThoroughCare was built to not only meet CMS’s care management program requirements, but our existing tools and capabilities were designed to support value-based care coordination and contracting no matter the payor.

Here, we outline the five areas where ThoroughCare helps provider organizations meet compliance standards, support value-based quality performance reporting, and improve patient satisfaction.

Care management compliance a competitive advantage

Every care management program has a set of regulatory, financial, contractual, and clinical rules or performance measures they need to comply with to be adequately paid for service delivery and outcomes. 

Whether through a fee-for-service program or value-based care arrangement, meeting these requirements promptly, accurately, and efficiently is critical to the program’s success. It’s also an essential differentiator in engaging, recruiting, and retaining quality clinicians and care team staff in a tight labor market.

A 2021 international study by Ethisphere found that “health-related small and medium-sized enterprises with high or medium ethics program maturity had stronger economic performance during the COVID pandemic.” Healthcare organizations that invested in robust compliance efforts realized a positive return on their investment in technology and training, as well as revenue. 

An organization’s success mainly depends on its ability to use technology that integrates workflows, captures data seamlessly, and automates accurate documentation. This makes it possible for providers and staff to achieve compliance as part of their daily professional activities. 

These capabilities not only enhance performance and quality but also improve financial metrics, making the organization more appealing to VBC payors and partners.

Manage any care coordination program

The core components of care coordination or a care management program create a foundation for value-based care arrangements with any health plan.

Because ThoroughCare is payor-agnostic, the platform can be used to manage any care coordination or care management program, including:

In fact, the software provides the underpinning needed to meet the rigors of any compliance- or value-based care-driven contracting. The platform provides analytics and reporting features across five compliance and VBC-related areas, as shown in Figure 1.

Screenshot 2024-04-24 144927

Figure 1: Five areas that ThoroughCare supports care management compliance and value-based care.

As we explore the five compliance, quality, and performance areas, consider how care coordination and care management capabilities support your goals regarding service delivery, care quality, organizational performance, and revenue

Care management program compliance

Every care management program, whether sponsored by the Centers for Medicare & Medicaid Services (CMS), a health plan, or an employer, has eligibility and enrollment requirements. 

Many care management programs focus on particular medical conditions, comorbidities, or population characteristics. In addition to who can participate, some programs have requirements around the types of clinical qualifications providers must have to provide the service.

Lastly, each type of program may have requirements around the following:

  • Specific evaluations or assessments that must be conducted
  • An initial, in-person appointment
  • Patient participation consent
  • Detailed services that must be provided, like goal or care planning
  • Volume or amount of time or interaction
  • Time-based constraints on how soon and how often touchpoints must begin

For example, Transitional Care Management has specific requirements for follow-up timing and activities that must be completed in a timely fashion. When an enrollee is discharged from the hospital, at least three of the following four steps must be performed.

Interactive content: 

  • Two outreach attempts must be made within two business days
  • Outreach attempts must be made by clinical staff who can address the patient’s status 

Non-face-to-face services: 

  • Must provide non-face-to-face services within the 30-day time frame
  • Services include coordinating community resources, providing education, sending referrals, and
  • reviewing discharge information

Face-to-face visit: 

  • Must provide one face-to-face visit using specific codes
  • For moderate complexity patients, the visit must be scheduled within 14 calendar days
  • For high-complexity cases, the visit must be scheduled within seven calendar days

Medication reconciliation and management: 

  • Medication reconciliation and management must occur on or before the face-to-face visit date

ThoroughCare provides the clinical workflow, standardized operations, and guided processes to help providers meet these specific requirements.

Billing requirements

Reimbursement rules set how time and equipment claims should be captured. They direct which services can be provided concurrently and how specific programs can be used collaboratively. 

For example, Chronic Care Management (CCM) works well with Transitional Care Management (TCM). However, billing rules state that CCM and TCM must not be billed for the same time period. When used together, providers must be aware of this constraint to ensure proper billing. 

Evidence-based care quality

Specific care management programs, or value-based contracts, may require that clinicians use evidence-based assessments and proven care approaches. 

For example, Chronic Care Management requires a personalized care plan to be created collaboratively, given to the patient, and a copy included in a certified electronic medical record. 

Specific tools, such as health risk assessments and clinically validated screening devices, such as those used in behavioral health or Annual Wellness Visits—PHQ-9 (Depression), GAD-7 (Anxiety), CAGE (Alcohol), DAST-10 (Substance Abuse), and MDQ (Mood Disorders)—may be required as part of program kick-off or regular check-ins.

Value-based performance

Innovation in team-based care management programs, such as hybrid payments for primary care, is helping providers transition from fee-for-service to value-based care.  The hope is that prospective payments and multi-disciplinary services can improve longitudinal outcomes, enhance primary care access, and save on costly chronic diseases.

Providers pursuing more risk in VBC arrangements must manage new care approaches and programs while reporting on cost-saving measures and quality performance metrics.

ThoroughCare provides robust and easy-to-use analytics along with a plethora of organizational, operational, clinical, and financial dashboards and reports. 

Our analytics capabilities and features help care teams improve quality which can lead to higher levels of compliance. This can yield more significant incentives and shared savings, including: 

  • Star Ratings
  • HEDIS scores
  • Accreditation and reaccreditation
  • Quality measurement compliance
  • Patient satisfaction and engagement scores

PHI data security and HIPAA compliance

HIPAA compliance is paramount regardless of the type of care management program, whether it includes digital communication, integrating data from various sources, or interoperability with an EHR or third-party technologies.

Personal health information (PHI) security and communication compliance focuses on legal and regulatory requirements defined by the Health Insurance Portability and Accountability Act (HIPAA), including the privacy, security, and breach notification rules.

In particular, to comply with the HIPAA Security Rule, all covered entities must:

  • Ensure the confidentiality, integrity, and availability of all e-PHI
  • Detect and safeguard against anticipated threats to the security of the information
  • Protect against anticipated, impermissible uses or disclosures that are not allowed by the rule
  • Certify compliance by their workforce

ThoroughCare provides HIPAA-compliant tools to capture and store patient and practice data, including:

  • Our comprehensive care coordination software solution meets all requirements regulated by HIPAA
  • It’s powered by Amazon Web Services, supporting multifaceted data security and privacy through encryption
  • It’s also backed by partnerships with many of the leading EHRs, including Allscripts, Athena Health, Dr. Chrono, Elation, and EPIC

As a cloud-based software platform, ThoroughCare enables integrated connectivity with EHRs, data exchanges, remote monitoring devices, and mobile applications. These provide an inclusive patient view throughout their care journey, allowing a more secure approach to bi-directional data access by patient and population.

For example, ThoroughCare provides group functionality, allowing control over data access across an entire healthcare organization, including individual care sites or office locations.

We focus on streamlining care across applications, programs, delivery channels, and quality measures with a security-forward approach. 

Beyond compliance to enhance patient engagement

Implementing a care management program focusing on care quality and compliance can provide value-added benefits beyond revenue and clinical outcomes.

Well-managed programs that drive performance, health improvement, and compliance tend to engage patients better and improve Star Ratings, Net Promoter Scores (NPS), and Customer Satisfaction Scores (CSAT).

This can be particularly powerful for organizations that want to demonstrate to payors, employers, and other value-based partners that they have the capabilities, technology, and oversight to innovate and impact care and cost. 

NCQA prevalidation supports patient engagement

ThoroughCare is recognized by the National Committee for Quality Assurance (NCQA) and has achieved NCQA prevalidation for population health management in health plan accreditation.

This prevalidation demonstrates that our platform has the functionality to help organizations achieve NCQA Accreditation in four program areas:

  • Health plan
  • Managed behavioral health organization
  • Case management
  • Population health

To receive NCQA recognition, ThoroughCare underwent a rigorous evaluation of its functionality, including but not limited to:

  • Reporting functions
  • Report examples
  • Screenshots
  • Live demonstrations
  • Other relevant documentation

For healthcare organizations prioritizing compliance and value-based care, prevalidation confirms that ThoroughCare’s data is analyzed according to industry standards. It further certifies that ThoroughCare’s patient engagement tools and clinical workflows are evidence-based and follow best practices. 

It also shows that the platform’s reporting capabilities align with national quality measures and support population health initiatives prioritized in value-based contracting.

Features that enable value-based care compliance

Guided questions and assessments

For Behavioral Health Integration, ThoroughCare’s workflow enables consistent compliance with:

  • Systematic assessments
  • Continuous patient monitoring
  • Care plan creation and revision
  • Treatment coordination
  • Maintaining a continuous relationship between the patient and a designated care team member

Solutions for Advance Care Planning walk clinicians through the advance directive process that depends on a consistent framework, omnichannel educational materials, and a set of evidence-based steps.

As part of the Annual Wellness Visit, the platform offers a standards-based health risk assessment that the patient can complete before the appointment or with a clinician. Simple and easy-to-follow questions guide the provider through the process of identifying risk factors, asking about current medical and mental health conditions, and providing recommended treatments.

Automated assignment of CPT codes

Every care management program covered by ThoroughCare provides robust time and service tracking and automatically assigns claims based on time spent with the patient and by whom.

For example, with Remote Patient Monitoring, ThoroughCare covers three different services and their corresponding CPT codes, including initial device setup, the RPM device itself, and ongoing time for reviewing patient data and managing the patient’s participation. This process is set up differently to ensure rural health clinics comply with their unique HCPCS billing code.

Time log prompts and alerts

In addition to automating CPT code assignment, ThoroughCare provides numerous ways to keep an eye on complying with billing time minimums, maximums, and other rules. The platform prompts clinicians to log non-face-to-face time with an integrated timer. Reports and dashboards provide real-time tracking and audit trail generation for billing and claims accuracy.

For RPM, the software prompts and guides device logging, charting patient data readings, and making evident any gaps in meeting the minimum required monthly readings.

Analytics dashboards and reports

ThoroughCare Analytics provides near real-time care management data to support insightful clinical analysis as part of compliance activities and meeting value-based care contract requirements. Analytics cover five measurement areas, including:

  • Strategic data
  • Clinical data
  • Engagement data
  • Financial data
  • Operational data

Through dashboards and reports, clinical teams and operational leaders can implement quality improvement initiatives, complete compliance reassessments, and audit clinical and billing data to demonstrate performance.

The platform offers robust analytics that delivers insights on metrics, including:

  • Clinical and operational trends
  • Indicate changes in patient health and outcomes
  • Staff efficiency and performance
  • Billing gaps and issues
  • KPI oversight
  • Track and trend specific patient goals over time
  • Assess goals versus barriers across patient populations
  • Identify interventions and monitor progress to gauge success
  • Assess patient vitals and trends over time
  • Manage and report on trends for multiple patient populations across care sites

ThoroughCare enables care management compliance

ThoroughCare helps providers comply with care management requirements and value-based contracts. 

Our comprehensive platform offers a singular tool to improve patient care coordination. Robust reporting and analytics enable provider organizations to proactively measure performance and quality.

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