Lucy Zielinski
Lucy Zielinski

The U.S. healthcare system is steadily transitioning from fee-for-service (FFS) reimbursement to fee-for-value (FFV) payment. This change has already started to affect medical practice revenue, and it will have an even bigger impact in the years ahead.

Unfortunately, most physicians and practice managers understand only part of the FFV equation. While they know the quality data they report to payers under FFV will affect their reimbursement, many do not understand exactly how payers use this data to adjust payment.

What is the missing piece of the equation? Patient risk scoring.

Under many value-based payment models, payers adjust reimbursement to reflect the relative health or sickness of patients. These adjustments are meant to reflect expected costs, so they can have a big impact on payment. In fact, depending on what risk factors are present, appropriate risk scoring can double or triple per-patient reimbursement.

The challenge is that patient risk scoring is complex. It is easy for medical practices to under-report risk and, therefore, to miss out on full reimbursement. There are some crucial challenges they must confront in order to understand and properly utilize patient risk scoring.

Lucy Zielinski is managing partner for Lumina Health Partners. This article originally appeared in the March 2019 issue of Group Practice Journal from AMGA. Download a complimentary reprint using the form below to read the rest of the article.