Compliance, Operations, and Value-Based Care

Financial performance, quality measurement, and compliance in most contracts, particularly value-based care arrangements, can significantly improve through tighter workflow coordination between payers and providers.  An ongoing problem is that health plans and care providers work from a different operational perspective, and generally rely on a different core data set. 


Coding for risk adjustment has become very risky for Medicare Advantage plans. CMS and the OIG have made it very clear that they are going to scrutinize HCC coding through additional audits and compliance regulations.  These expose payers (and providers) to risk of increased denials, False Claims Act litigation, and extrapolation.  So how can health plans and their coding vendors assure coding compliance without undue burden on the providers?   A TEAM-Playbook that coordinates the TEAM-Work between the providers, health plan, and coding vendors.  TEAM of Care inserts automated workflow steps that flag high priority codes, identify gaps, and assign follow-up tasks across all parties.  The result is a closed-loop process that improves accuracy, improves compliance, and reduces the costs of audit activities.

Financial performance, quality measurement, and compliance in value-based care arrangements can significantly improve through tighter workflow coordination between payers and providers.  TEAM of Care has improved risk adjustment performance, increased quality scores, reduced compliance risk, and reduced the cost of audits with our workflow coordination system.

Of course, your health plan has operational best-practices, policies, and procedures.  When there are opportunities to improve operational performance, how do you isolate those for evaluation and redesign.  What about compliance policies that need to change based on new regulatory guidance?  When you make updates, how do you operationalize those changes?  Is everything distributed to everyone all at one time?  With a TEAM-Playbook, you can view your processes, make changes, and distribute them in a matter of minutes, hours, or days.  TEAM-Work and TEAM-Management change immediately upon deployment.

Impact on TEAM Members

Executives can design risk-based contracts with increased confidence that health plan staff, clinical partners, and third-party vendors can deliver on requirements necessary to meet financial objectives, while enhancing capability to adhere to regulatory requirements.   Managers have the tools they need to define the tactics and measure performance that support those objectives.  TEAM of Care is uniquely designed to track what work has been done and whether it is making an impact.

Les “ings” per hour.  Scheduling, coding, billing, documenting, finding missing charts, looking for results, confirming completed activities….  These are the “ings” that take more time, more energy, and more frustration than they should. Administrative TEAM members are more efficient and more effective with automated workflows that are easy to access and easy to complete.

  • By presenting clear, consistent, repeatable actions across the entire TEAM, you will have full documentation of your compliance processes and distribute current coding guidance across the entire TEAM in a matter of minutes.
  • Because the process is built-in to the system, you know that operations actually reflect your policies and procedures, with an automated audit trail to back it up.
  • Direct visibility to actions assures that claims that could create regulatory or financial risk never fall through the cracks.
  • The system also establishes an audit trail of activities and document exchange, reducing the cost of exception handling and audits. 

Take the burden off the IT staff to create magical solutions.  TEAM of Care uses industry standard data exchange APIs that improve connectivity between the health plan, vendors, and clinicians for coding, billing, and clinical documentation exchange. 

TEAM of Care establishes hooks that automatically trigger tasks and chart retrieval for an appropriate subset on codes or encounters based on data from provider EHRs.  The system automatically sends the encounter record for a specific date of service to the coding vendor.  This is a proactive step to confirm the chart supports the code before the plan submits the claim for payment and reduces the “chase list” between the parties. 

Benefits to the Health Plan

TEAM of Care works with health plans and other risk-bearing organizations to offer an entirely new level of payer-provider integration. Using TEAM of Care’s unique approach, health plans enable their clinical partners to improve medical loss ratios (MLR) and star ratings with automated and streamlined clinical interventions that occur before costs and gaps occur.