Risk Adjustment: Determining Risk Determines Reward

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Transcript of Risk Adjustment: Determining Risk Determines Reward

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Risk AdjustmentWhat is it?

Methodology accounting for known and/or discovered health data elements and levels comparisons of wellness among patients.

Used as a method to evaluate all patients on an equal scale.

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Determining Factors

Risk adjustment modules utilize diagnosis codes to determine potential patient level risks.

• Age• Gender• Socioeconomic Status• Disability Status• Insurance status

- Medicare- Medicaid,- Dual-eligible, etc.

• Claims data elements such as procedure codes, place of service codes, etc.

• Special patient-specific conditions (enrolled in hospice or being an ESRD patient)

ADDITIONAL ELEMENTS

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Risk Adjustment Modules

Diagnosis based programs

HHSHealth and Human Services

Hierarchical Condition Category

CDPSChronic Illness and Disability

Payment Systems

HCC-CHierarchical Condition

Category, Part C

DRGDiagnosis Related Groups

ACGAdjusted Clinical Groups

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H H CMedicare

Hierarchal Condition Categories

• Model used by MA plans

• Takes ICD codes and filters them into Diagnosis Groups, then into Condition Categories

• Assigns a value to each diagnosis code in the model

• Each diagnosis code carries a Risk Adjustment Factor

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How does Risk Adjustment Affect You?• Physicians will treat patients on plans

funded through RA models

• Plans expect providers to document and code diagnoses correctly

• Physician documentation and coding establishes the complexity and workload of patient panels

• Documentation and diagnoses become the basis for funding and reimbursement

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How is the risk (RAF) score developed?

Each patient has a RAF score made of: Baseline demographic elements (age/sex and dual eligibility status) Incremental increases based on HCC diagnoses submitted on claims from face-to-face encounters with qualified practitioners during the

calendar year

HCC coding is prospective in nature: The work you do in this year sets the RAF and subsequent funding for next year

All models include chronic conditions that do not change from year to year:Diabetes, COPD, CHF, Atrial-Fib, MS, Parkinson’s, Chronic Hepatitis

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Correct Coding

• Adherence to ICD-10 guidelines is required under HIPAA

• Documentation must show condition was monitored, evaluated, assessed, or treated (MEAT)

• A diagnosis code may only be reported if it is explicitly spelled out in the medical record

• No coding from problem lists, super bills, or medical history

Treatment is prima facia evidence of a diagnosis—if you are treating, it exists

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MEAT the Chronic Condition

Monitor

Signs Symptoms

Disease progression Disease regression

Evaluate

Test results Medication effectiveness Response to treatment

Assess

Ordering tests Discussion

Review records Counseling

Treat

MedicationsTherapies

Other modalities

M E A T

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HCC Financial Differences in Coding Specificity

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Risk Adjustment Data Validation

• CMS identifies a random stratified sample of patients to audit.

• Only Part C HCCs are audited in a RADV.

• Health plans must submit up to five best records demonstrating diagnoses that support the HCC values paid as current in the year being audited.

• Supplemental diagnoses (those not originally submitted via claims) may be approved if they are documented as current diagnoses in the record.

• E submission of all diagnoses (with HCCs) are cumulative, so there may be a negative or positive financial outcome overall in such an audit.

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Health and Human ServicesHCC Model

• Section 1343 of the Affordable Care Act (ACA) calls for a risk adjustment model. Health and Human Services (HHS) created a risk adjustment model based on the HCC classification system; however this model was developed using commercial claims.

• The hierarchical grouping logic is similar to the Medicare methodology, but HHS selected a different set of HCCs for the federal risk adjustment methodology to reflect the population differences.

• Patients are grouped in this model by age (adult,child,infant) and by metal (platinum, gold, silver, and bronze).

• This plan does not currently review prescription-based diagnoses such as those found in the HCC-D used by Medicare.

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ACA Plan

ACA Plan Category The insurance company pays

The patient pays

Platinum 90% 10%

Gold 80% 20%

Silver 70% 30%

Bronze 60% 40%

Catastrophic Less than 60% More than 40%

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Medicaid Chronic Illness and Disability

Payment System (CDPS)• In the Medicaid Chronic Illness and Disability Payment System (CDPS)

risk adjustment model, there are far more diagnosis codes identified than are included in the Medicare HCC model

• While these CDPS diagnoses also carry a numeric value for risk, they are also rated as “high,” “medium,” and “low” risk overall.

• This rating is used in hierarchal value setting. Where low is trumped by medium and medium is trumped by high.

• Uses data from both claims and Medicaid prescriptions (MRx)

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Cardiovascular Category

CARVH3 Stage 1 groups 7 diagnoses

CARM 13 Stage 1 groups 53 diagnoses

CARL 26 Stage 1 groups 314 diagnoses

CAREL 2 Stage 1 groups 35 diagnoses

Four Levels

The suffix of the Cardiovascular Category (CAR) establishes its place in the hierarchy:

• VH (Very High) (weight 2.037): heart transplants, valves, etc.• M (Medium) (weight 0.805): heart attacks, etc.• L (Low) (weight 0.368): heart disease, etc.• EL (Extra Low): hypertension, etc.

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Why is HCC Risk Adjustment Important ?

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CMS RA Payment Schedule

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MIPS and Risk Adjustment

HCC coding is the system that will be used for Risk Adjustment under MIPS.

At its core, diagnosis codes (ICD-10) are assigned a weight that measures patient acuity. Medicare expects that patients with higher HCC scores will consume more healthcare dollars and have worse outcomes.

If 60% of the MIPS score for providers is going to come from risk adjusted quality and resource use scores, it is critically important to accurately reflect the acuity of their patient population. Doing so will allow their quality and cost scores to accurately reflect the excellent care provided by physicians.

Your diagnosis coding is about to become much more important, both for immediate fee-for-service reimbursement and over the following two years as Medicare uses that diagnosis data for Risk Adjustment under MIPS.

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CareOptimize Coding Module

• Integrates into the physician workflow at the point of care (Inside EHR)

• Automates coding gaps detection for more accurate coding and risk scoring (Identify missed HCC codes)

• Conducts prospective and retrospective coding (Improve RAF scores)

• Analyzes projected coding patterns and provider documentation gaps

• Improves care planning and patient outcomes

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CareOptimize Coding ModuleStratify Patients by RAF Score Potential

Patient Specific RAF Scores and Opportunity Count

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CareOptimize Coding Module

Patient Specific HCC Code History and RAF Score