RISK ADJUSTMENT · 2018-05-24 · HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS . Implementing...

RISK ADJUSTMENT Cracking the Code

DANIEL WEINRIEB SENIOR VICE PRESIDENT, HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS

Copyright © 2015, Gorman Health Group, LLC

Government Programs Leading enterprise of national consulting services and software solutions for payers and providers.

Our Mission

Our mission, as the industry’s most active professional services consultancy and provider of technology-based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at lower costs, while serving as valued, trusted partners to government health agencies.

Washington, DC

Headquartered in Washington, DC with more than 200 staff and contractors nationwide with over 2,000 combined years of Government Programs experience.

Leadership

Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS) regulatory expertise.

Privately Owned

Founded in 1996

Gorman Health Group is the leading solutions and consulting firm for government-sponsored health programs.

WHO IS GORMAN HEALTH GROUP?

2


Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICAL Changing how you approach Medical Management, Quality and Stars

PROVIDER INNOVATIONS Supporting network design and medical cost control implementation

OPERATIONS Bringing excellence to every aspect of your implementation from enrollment to claims payment

COMPLIANCE Offering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACY Leading experts in Part D, PBM, formulary and pharmacy programs

HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS Implementing cross-functional risk adjustment programs for medical trend management and quality improvement

STRATEGY & GROWTH Leading experts in Marketing, Sales and Strategy development that create short and long-term profitable growth

BROAD SERVICES

3


Dedicated to assisting Medicaid Managed Care Organizations achieve strategic, operational and quality goals across five verticals.

CLINICAL Blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership.

STRATEGIC POSITIONING Analyzing and evaluating organizational adaptability, and readiness for change in new policy and population management environments.

QUALITY PROGRAM OVERSIGHT Guidance and support to achieve the results your members and regulators expect while attaining compliance with State and Federal rules.

FINANCIAL ALIGNMENT Providing health economic solutions for the needs of the Medicaid population including long-term care, behavioral health, and chronic condition management.

OPERATIONS Creative solutions to maximize cost effectiveness, and deliver lasting results from eligibility to provider contract management, and claims.

MEDICAID SERVICES

4


• 2016 Call Letter o Insights and Impacts on Risk

Adjustment • Have You Heard? There Are Risk

Adjustment Vendors! o Vendor Selection, Integration, and

Oversight • Provider Partnerships

o Value in Collaboration

AGENDA

5


2016 CALL LETTER

Impacts and Insights on Risk Adjustment


• For payment years 2014 and 2015, CMS used varying, weighted percentages from the 2013 and 2014 CMS-HCC models, blending the resulting risk scores from each model.

• For payment year 2016, CMS will only use the 2014 HCC Risk Adjustment Model. • The full implementation of the 2014 model is the most significant factor offsetting the

increases to the benchmarks: a 1.7 percent reduction. This is because the 2014 model excludes several diagnoses that CMS believes were being coded very frequently by certain MA plans that were “most aggressive in coding,” such as stage 1-3 chronic kidney disease and polyneuropathy.

• CMS states that removing these diagnoses “makes the payment system fairer.”

However, this means that payments to plans for beneficiaries with those chronic conditions will be reduced. As a result, plans with disproportionately large numbers of beneficiaries with chronic conditions, such as special needs plans (“SNPs”), will face larger reductions.

• CMS will evaluate the impact of the model on partial/full duals as well as LIS and will

determine if additional adjustments need to be made to model.

END THE BLEND

7


• MA coding adjustment is a methodological adjustment to risk scores to ensure payment accuracy given differential coding patterns in MA and FFS.

• Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between Medicare Advantage organizations and FFS providers. In CY 2016, CMS proposes to make an adjustment reflective of the statutory minimum.

• CMS has increased the adjustment factor for MA coding pattern

differences by 0.25 percent, the lowest amount possible under the statute. As such, the updated adjustment factor for 2016 is 5.41 percent.

CODING PATTERN ADJUSTMENT

8


• The 90/10 rule: 90% RAPS / 10% Encounter Data • Filtering logic and final report layout are yet to be released = mad dash to conduct an

impact analysis on risk score with the change. • CMS is not planning to calculate encounter data-based risk scores using data

collection for years prior to 2014. • CMS will apply the 90/10 rule until we implement “risk adjustment using Medicare

Advantage diagnostic, cost, and use data,” meaning until they have recalibrated the model using MA encounter data.

• Of note: the encounter data system accepts diagnoses obtained through chart

review, MAOs will be able to submit the same diagnoses that they have been submitting into the RAPS.

• Given that the encounter data system does not change the definition of acceptable

diagnoses or limit their submission, CMS anticipates that the risk scores calculated using encounter data will reflect the same coding trend as those calculated with RAPS-based diagnoses.

ENCOUNTER DATA AS A SOURCE FOR 2016

9


• As proposed in the 2016 Advance Notice, the data collection year for risk scores used for 2016 payment will use diagnoses from the prior calendar year (CY2015).

• CMS held firm stating that NO payment adjustments or hold harmless policies will be made to accommodate the transition to ICD-10 and the correlation to Risk Adjustment.

• CMS cannot accept or process ICD-9 codes for risk adjustment for services

with dates of service beginning October 1, 2015.

• Reminder: Plans have until at least January 31st after the payment year to submit accurate risk adjustment data (which includes both submissions to the RAPS and the Encounter Data Processing System). o Specifically, MAOs have until January 2017 to submit encounter data and RAPS

risk adjustment data from 2015 dates of service.

• Be on the look out for the final ICD-10 Mappings

ICD-10

10


• Update to reflect the 2016 benefit structure

• Updates to the data years used to calibrate the model • Clinical update to the diagnoses included in some prescription drug

hierarchical condition categories (RxHCCs)

• Inclusion of Part D data for Medicare Advantage- Part D sponsors in the model calibration

• An actuarial adjustment to the Chronic Viral Hepatitis C RxHCC. • High cure rates of these new chronic Hepatitis C medications pose a

challenge as CMS’s prospective RxHCC model which is designed to predict future costs based on historical data and is not prepared to account for disease costs that are diagnosed, treated, and cured within one year.

RXHCC MODEL

11


• CMS has taken the stance that In-Home Assessments bring value-

HOWEVER, they have outlined a two pronged approach to the delivery and oversight of assessments:

o Adopt a core set of components and best practices for In-Home

Assessments o Track subsequently provided care: In CY 2015, CMS will track and

analyze care provision following in-home visits.

IN-HOME ASSESSMENT

12


• Only diagnoses from risk adjustment acceptable physician specialty types may be submitted for payment purposes.

• Flag diagnoses resulting from In-Home Assessments when reporting diagnoses to CMS for risk adjusted payments.

• All components of the annual wellness visit, including a health risk

assessment such as the model health risk assessment developed by the CDC

• Medication review and reconciliation • Scheduling appointments with appropriate providers and making

referrals and/or connections for the enrollee to appropriate community resources

IN-HOME ASSESSMENT BEST PRACTICES

13


• Conducting an environmental scan of the enrollee’s home for safety risks, and need for adaptive equipment

• A process to verify that needed follow-up care is provided • A process to verify that information obtained during the assessment

is provided to the appropriate plan provider(s) • Provision to the enrollee of a summary of the information, including

diagnoses, medications, scheduled follow-up appointments, plan for care coordination, and contact information for appropriate community resources

• Enrollment of assessed enrollees into the plan’s disease

management/case management programs, as appropriate.

IN-HOME ASSESSMENT BEST PRACTICES

14


TO VEND OR NOT TO VEND

Risk Adjustment Vendor Selection, Integration, and Oversight


PURPOSE • Conduct a market scan to

identify industry leaders in the risk revenue management space, supporting risk adjustment, population health management, provider/ member engagement activities, and avoid Risk Adjustment Data Validation (RADV) exposure.

GOAL • Select vendor finalists and

determine a strategy for a vendor management model that can integrate both data and processes, ensuring maximum financial and quality of care/service outcomes for the communities in which we serve.

PURPOSE AND GOAL

16


CASE STUDY 1

17

Missing or truncated codes significantly impact the revenue potential of health plans.

The Problem

With all conditions coded by Vendor A certified coders, our clients can be appropriately paid for their member population—in some cases, that increase can amount to 400% annually.

The Solution

$27,159 =

All Conditions Coded (Chart Data) RAF 2.497

$12,508

Some Conditions Coded (Claims Data) RAF 1.150

217%

Total Increase

The Findings


CASE STUDY 2

18

CMS recognizes the need to pay Medicare Advantage plans appropriately for each member, based on their total health picture. However, up to 32% of all medical records contain unsubstantiated diagnoses.

The Problem

By capturing all conditions in a coded review, Vendor B enables its clients to realize appropriate revenue over a claims-only view of a patient’s health profile. To ensure accuracy and compliance, our quality assurance program is one of the industry’s most comprehensive. For each program, we audit no less than 5% of each coder’s work and 100% of charts yielding new HCCs.

The Solution

The Findings

$824 M Additional Risk-Adjusted Revenue, 2012–2013

4.6 M Client Medical Records Retrieved & Coded, 2013


• Range varies depending upon how aggressive the client wants to be.

RETURN ON INVESTMENT (ROI) SUMMARY Our findings

19

2X

4X

13X

ROI vs. Revenue Vendor C has routinely helped our clients meet or exceed their revenue goals.


Vendor A $ 4.4 M Analytics and Chart Retrieval and Coding Review • Medicaid Chart Review and Coding: HOLD • MSA Chart Review and Coding: 7/31/15 • EDPS/RAPS Submission: 9/30/15 • In-Home Assessment Targeting Analytics: 7/31/15

Vendor B $ 4.1 M Chart Retrieval and Coding Review • Medicare: 5/1/15 • Commercial: 9/1/15

Vendor C $ 1.4 M In-Home Assessments (Some HEDIS Gap Closure) • Medicare: TBD

Vendor D $ 0.9 M Analytics (Commercial Exchange and In-Home Assessments/Some HEDIS Gap Closure) • Analytics on Small Group/Individual: 3/31/15 • Medicare In-Home Assessments: 12/31/14

Vendor E $ 0.2 M In-Home Assessments • Medicare: Complete

Vendor F $ 0.1 M Out of Area Chart Retrieval and Coding Rev • TBD

$11.1 M

CURRENT STATE Vendors, Costs, and Contract Term Dates

20


VENDOR SELECTION

• Enterprise-wide effort • RFI and RFP development • Review and score responses in the following business functions:

o Corporate Partnership and Integration o Analytics o Retrospective Review and Processes o Prospective Strategies o EDPS/RAPS Data Submission Process o HEDIS/Care Coordination Alignment o Compliance and RADV Risk Mitigation Process/Experience o Technology

• Conduct onsite demos • Reference checks

21


VENDOR MANAGEMENT OPTIONS Comprehensive Model (Sample)

22

BIG VENDOR

Analytics

Chart Retrieval/Storage

Coding Review

IHA’s

AWV EDPS/ RAPS

RADV Mitigation

HEDIS/ Quality

Member/Provider


Health Plan

Vendor Analytics

Vendor Chart

Retrieval

Vendor Coding Review

Vendor Computer Assisted Coding Vendor

Member/ Provider

Vendor IHA

Vendor RADV

Mitigation

Vendor AWV

VENDOR MANAGEMENT OPTIONS

Integrated Model (Sample 1)

23


Vendor All

Products/ Services

Vendor Analytics

Vendor Supplemental Chart Retrieval

Vendor Computer Assisted Coding

Vendor AWV

VENDOR MANAGEMENT OPTIONS Integrated Model (Sample 2)

24


Comprehensive Model

• Pro: One strategic partner, one contact • Pro: One Contract and SLA • Pro: Streamlined oversight • Pro: One source of data outputs for internal integration • Pro: Potential reduction in admin expense • Con: All eggs in one basket

Integrated Model

• Pro: Selected specialists in their field (business function expertise)

• Pro: Potential reduction in admin expense • Con: Disparate vendor oversight processes • Con: Vendor data and process integration • Con: Multiple contract negotiations, SLAs, and timelines • Con: Various data sources to integrate internally

PROS AND CONS Program Risks and Rewards

25


• Action: Select preferred vendor management model o Generate buy-in, executive approval, and

accountability • Action: Plan next steps accordingly

o SLAs, SLAs, SLAs • Goal: Avoid off-the-shelf products and

solutions o Vendors cannot/should not dictate the

strategy

DECISION Recap and Next Steps

26


PROVIDER PARTNERSHIPS

Value in Collaboration


• HEDIS: Stars, Commercial, NCQA • CAHPS: Patient and Provider Experience • Clinical Program Development and Care Management • Engagement, Support, Incentives

Quality

• Leverage Analytics • Population Health Management • Provider Practice Transformation and Engagement • Specialists and Mid-Level Engagement

Trend

• Quality of Care and Service Bonuses • Risk Revenue: Documentation and Coding (RCM) • Operational Efficiency • Provider Engagement and Performance Measurement

Growth

BUSINESS OBJECTIVES Visible Overlap

28

Deliver Quality, Cost-Efficient Care to Patient - Manage Patient Health


Health Plan Provider Engagement

HEALTH PLAN: CURRENT STATE

29

Fragmented Initiatives, Competing Priorities, Data Overload


CURRENT STATE OF AFFAIRS: OR IS IT?

• Identify trends and opportunities through an opportunity analysis • Leverage current reporting • Prioritize engagement

Target

• Partner with Office Leaders and Physician Champions • Conduct initial engagement meeting • Identify opportunities • Discuss next steps

Engage

• Link with Clinical Care Coordination Team • Outline practice action plans and next steps • Define roles and responsibilities

Align

• Deliver solutions

• Clinical action plans • Operational action plans

Implement

• Trend • Quality • Engagement

Measure

30


PROVIDER ENGAGEMENT OBJECTIVES

31

Greater consistency of high-quality care delivery from a trusted source - their providers - through patient-centered tools and approaches

• Leverage IT to support communication and collaboration between PCPs, specialists, and patients

Demonstrate provider quality and medical management to current and future patients, government entities, health plans, and employers

• Enter into physician-supported "pay-for-value,” additional contractual arrangements

Partnership between the health plan and healthcare providers, hospital systems, and the community

• Demonstrate superior clinical quality outcomes, manage medical costs, realize population health

Effective employer management of employee/dependent healthcare costs

• Through the purchase of better, more efficient healthcare services

Develop more collaborative relationships between hospitals and medical staff


• Physicians from multiple specialties, with the support from the health system and the health plan, can collaborate to maximize the value of the healthcare services they provide to their patients. In order to do so, key stakeholders must commit to:

CONCLUSIONS

32

Continuously identifying and adopting operational and clinical measures to assess the value of care provided in the inpatient, outpatient, and physician office settings

Using an information technology system to track and report provider and health plan performance with these measures

Collaborating with employers and health plans to develop provider-supported contractual and incentive payment arrangements to ensure ongoing availability of new, high-value healthcare

products

Holding each other accountable for their performance in regards to these measures


• Leverage and integrate data and processes o Is MRA included in your Medical Management and Quality Improvement Strategies? AND

Pharmacy! o Do your systems talk to each other: Interoperability and Integration o Show me your spreadsheet!

• Partner with your partners: Quality over Quantity o Convene with your vendors and coordinate efforts o Ensure compliance, patient-centered care and reduce provider abrasion o Use Provider Incentives wisely

• Targeted, Meaningful, Valuable, Actionable Provider Engagement and Education

o Deliver results: Good and Bad o What is your strategy to engage specialists? o Support Practice Transformation Models through incentives

• Evaluate your current infrastructure to support Clinical Documentation o More than just Coding- Population Health Management

KEYS TO SUCCESS Comprehensive, Integrated, Compliant MRA Programs

33


• For health plans: Make sure you are prepared for ICD-10, studies show that

your providers don’t think you are o Have you modeled the impact to your Risk Score? o Are you prepared for DENIALS?

• In-Home Assessments: Bring the PCP’s back into the fold

o Target based on complexity and patient care needs, not a money grab o Care Coordination and medical management is key- align with quality

• Shift your chart review and storage strategy

o Retrospective chart reviews…transition to concurrent chart reviews, not a last stich effort o Do you have a Clinical Documentation Improvement (CDI) strategy? o Use targeting strategies for patient and provider engagement, not just code collection

• Benefit Design and New Member Onboarding

o Pilot new strategies to gather comprehensive patient data from the beginning o Engage providers for preventive services off the bat

KEYS TO SUCCESS

34


Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned health care regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client’s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles the capitation payment of more than six million Medicare beneficiaries and continues to support customers participating in the Health Insurance Exchanges. Nearly 3,000 compliance professionals use the Online Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 45,000 brokers and sales agents are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman University™ training courses.

We are your partner in government-sponsored health programs

T

E

DANIEL WEINRIEB Senior Vice President, Healthcare Analytics and Risk Adjustment Solutions

(202) 774-8016

[email protected]

35

RISK ADJUSTMENT · 2018-05-24 · HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS . Implementing...

Documents

Transcript of RISK ADJUSTMENT · 2018-05-24 · HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS . Implementing...