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Fundamentals for Success in Value-Based Payment Models

Session Information:
By: Patrick Sulzberger, CPA
Format: On-Demand Webinar
Duration of the training: 60 Minutes

Conference Material (Password Required)

During this webinar, we will cover the fundamentals of how the transition to value-based payment models will impact the organization’s revenue stream, and the role providers and the revenue cycle team will play in succeeding in patient risk-adjusted payment models. We will also cover some examples from chart reviews of common opportunities for improvement in the area of capturing and reporting both primary and tertiary diagnoses at the highest level of specificity.

Learning Objective:
  • Attendees will understand the fundamentals of a “patient risk-adjusted” payment model and the role of diagnoses and demographic data
  • Attendees will learn the fundamentals of “mapping” from diagnoses to Hierarchical Condition Categories, and how that impacts risk scores
  • Attendees will understand the importance of both primary and tertiary diagnoses and how they impact payment in a patient risk-adjusted payment model
  • We will discuss and define key terminology that are fundamental to patient risk payment models
  • We will cover the role that revenue cycle team members and physicians / providers will play in the success of the organization under patient risk payment models
  • We will utilize examples from chart reviews performed by CCI to illustrate common areas of risk and opportunity identified, and the role of reports and education
Areas Covered in the Session:
  • Value-based Payment Models
  • Patient-Risk Adjusted Payment Models
  • Analysis of Diagnoses and Demographic Data
  • Mapping
  • Primary & Tertiary Diagnoses
  • Value-Based Healthcare
  • Value-Based Paradigm
  • Payer Priorities Under FFS / PPS
  • Payer Priorities – Value-Based
  • Transitioning Payer Motivations
  • Terminology
  • Patient Risk to a Payer
  • Patient Risk Example
  • Centers for Medicare & Medicaid Services (CMS)
  • CMS-HCC Examples
  • CMS-HCC Weights
  • CMS-HCC Risk Adjustment Model
  • CMS-HCC Disease Hierarchies
  • Hierarchical Condition Categories (HCC)
  • HCC Volumes – State 1
  • HCC Volumes – State 2
  • Most Frequent ICD-10 – HCC Mapping
  • HCC Descriptions & Weights
  • Aggregate HCC Weight – State 1
  • Aggregate HCC Weight – State 2
  • Example by Individual Provider
  • HCC Disease Hierarchy Example
  • HCC Example
  • ACO Example
  • Value-Based Model Characteristics
  • Implications
  • Summary of Results from Pilot Facility Reviews
  • Pilot Data
  • Documentation & Coding Risk
  • Implications for Success
Suggested Attendees:
  • CFOs
  • CEOs
  • Revenue cycle team members
  • Healthcare Providers
  • Physicians
  • Nurses
  • Billing Specialists
  • Administrators
  • Reimbursement Staff
Presenter Biography:

Patrick Sulzberger, CPA has 25 years of healthcare experience working as an operations improvement consultant with a focus on corporate compliance and revenue cycle. Patrick’s focus is assisting healthcare organizations to position themselves for sustainable success in a rapidly changing environment. Patrick assists his clients with developing a culture of change readiness, supported by processes that eliminate waste, resulting in improved compliance, improved quality, improved cash flow, and improved strategic positioning.


  • Corporate Compliance
  • Operational / Performance Improvement
  • Revenue Cycle & Charge Capture
  • Strategic Planning
  • Value-Based health care

Areas of Industry Focus

  • Physician practices
  • Federally Qualified Health Centers
  • Rural health clinics
  • Hospitals and health systems

Industry/Community Involvement

  • Member of the Health Care Compliance Association (HCCA)
  • Business Partner of Medical Group Management Association chapters
  • Speaker for several healthcare associations including:
    1. National Association of Community Health Centers (NACHC)
    2. Medical Group Management Association (MGMA) Chapters o Health Care Financial Management Association (HFMA)
    3. State Hospital Associations o State Primary Care Associations
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