Navigate Changing Reimbursement Models With These Industry Best Practices

One of the most profound changes in recent years is related to changing reimbursement models with the industry continuing to shift away from fee-for-service contracts to value-based care. Instead of tying revenue to the sheer volume of care provided, government and commercial payers have transitioned to new incentive models that take into consideration the quality and cost of care provided and client outcomes.

To succeed under this new paradigm, behavioral health and human services organizations need to modify their model of care delivery and operations to take this shift into consideration. If your agency participates in Medicare and Medicaid Electronic Health Record (EHR) Incentive and other value-based care programs, you can leverage these industry best practices to help protect your bottom line and support better client outcomes.

1. Leverage a comprehensive library of assessment instruments

If you are charged with demonstrating high performance, you need a library of research-backed assessment instruments to monitor your client’s progress towards their individual goals and objectives.

To streamline workflows, look for an electronic health record (EHR) vendor that integrates clinical assessment and outcomes instruments at the point of care. By measuring client progress along the way, you can identify opportunities for improvement in service delivery and support better outcomes.

2. Operationalize your clinical practice improvement activities (CPIA)

Clinical Practice Improvement Activities (CPIA) are related to the Merit-Based Incentive Payment System (MIPS) and counts for 15% of a provider’s score as part of CMS’ Quality Payment Program.

There are eight subcategories of CPIA activities including: Population Management, Care Coordination, Beneficiary Engagement, Patient Safety and Practice Assessment, Achieving Health Equity, Emergency Response and Preparedness, Integrated Behavioral and Mental Health and Expanded Access to Care.

MIPs-participating organizations can demonstrate an enhanced focus on quality and performance by creating and implementing a plan to support activities within these core areas of focus.

3. Invest in creating and maintaining outcomes management programs

Do you have a clear line of sight into the effectiveness of your approach to care? Does your team collaborate enterprise-wide to fine-tune your treatment plans to continually raise the bar in terms of care quality?

For organizations with a large portion of their revenue tied to client outcomes, it’s important to invest in developing and maintaining effective outcomes management programs.

That’s why it’s important to leverage an electronic health record (EHR) platform that simplifies the tasks associated with collecting the metrics that matter for your organization. By gaining more visibility into information about your client population, you can develop more targeted and effective outcomes management programs and action plans.

4. Monitor expenses and usage

While support better client outcomes is your number one priority, you also need to measure and monitor the expenses associated with delivering quality care.

If you participate in a value-based care model, your organization should be able to easily access the information you need to answer these questions associated with cost and care delivery:

  • What are the costs associated with delivering specialized therapies per each diagnosis type?
  • What clients represent outliers and deviate from the average cost to deliver care in comparison to your overall population?
  • How do you allocate fixed costs?

5. Increase client engagement

Helping clients assume a more proactive role in their health is one of the most powerful tools available to help you both control costs and foster improved outcomes.

In fact, in one recent study, nearly three-quarters of patients said that if it was easy to electronically access their own healthcare data, it would improve their understanding of their health and patient-to-physician communication.

And, it doesn’t have to be overly complex. Simply by leveraging smartphone apps and online patient portals, you can still reap tremendous results – helping to prevent conditions from worsening into adverse events that require complex (and costly) interventional care.


By taking a proactive role in your journey to value-based care, your organization can successfully navigate change while also protecting your bottom line – now and well into the future.

The Department of Health and Human Services aims to tie 90 percent of all Medicare fee-for-service to some kind of value metric.

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