The Best Kept Revenue Secret in Healthcare

Currently, the U.S. spends two to three times as much per capita on healthcare as most industrialized countries. Quality of care, however, is not directly tied to spending. The U.S. ranks 28th—below almost all other wealthy countries—when it comes to the quality of its healthcare.

In response to the quality dilemma, the Centers for Medicaid and Medicare Services (CMS) has taken steps to lead the healthcare industry into a value-based world—or one in which physician reimbursement is tied to quality and outcomes rather than the volume of service delivered. In driving this shift, the Medicare Access and CHIP Reauthorization Act (MACRA) legislation has been a cornerstone of CMS’ strategy.

Essentially, MACRA focuses on reimbursing physicians for what it has defined as value, rather than volume. In many cases, this means reimbursing for wellness-based care including annual wellness visits, smoking cessation programs, and weight loss coaching. It is for this reason that MACRA is the single largest revenue opportunity for healthcare payors and providers today. However, most are not taking the simple steps needed to capture this new revenue.


In other words, providers can capture significant dollars available to those who put effort into their performance in accordance with MACRA policy. For larger physician practices and health systems, the value amounts to tens of millions of dollars in new revenue.


With an understanding of why to get started, the more important question is how. The good news is it is often unnecessary to ask providers to do anything more than they are already doing. In many cases, providers are already delivering wellness services, but aren’t documenting them because they’re not aware such services are reimbursable.

MACRA revenue opportunities can be simply and quickly sized by evaluating a provider’s top ICD codes and their QRUR reports. If the opportunity exists, there are several actionable tactics that are mutually beneficial for the provider, payor, and—most importantly—the patient. Tactics include wellness program development, staffing optimization, workflow optimization, strategic recruiting, training, tool implementation, and EHR refinement.


While results vary by practice, we’ve helped clients achieve measurable results including a 28 percent increase in Medicare Part B reimbursement and $100,000 in new revenue per PCP.

By working with payors to help them engage and incent their most impactful provider groups, we’ve helped a larger network provider practice increase its HCC rating from 0.8 to 2.5, increase its STAR rating from 2.0 to 4.5—in addition to generating an additional $60 million in revenue.

Healthcare organizations: the value-based future is yours to build. MACRA is the ideal place to get started.