Risk Adjustment User Group
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A training initiative presented by
2007
/ 20
08 M
onth
ly
Risk Adjustment User Group
December 2008
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Welcome to the NovemberUser Group
• Introduction• Payment Process• Data Validation• Operations Update• Questions and Answers• Closing
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INTRODUCTION
• All attendees must pre-register• It is only necessary to register once• Retain unique PIN for all sessions• Session will last for one hour• Session slides will be available by
the Tuesday before the session • Panel will answer questions during
the Q&A portion of the session
User Group Process
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INTRODUCTION
• The 2008 monthly Risk Adjustment User Group Q & A and Notes documents are posted at the CSSC Operations website.
• Please continue to review the website for updates to this information.
www.csscoperations.com/new/usergroup/usergroupinfo.html
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PAYMENT PROCESS
Duplicate Diagnosis Cluster Submissions I. Definition:
A duplicate diagnosis cluster is one with the same attributes: -HIC Number -Provider Type -From Date -Through Date -Diagnosis Code
II. Cluster with the same attributes will receive 502 Error Message, which is:
(“Diagnosis clusters was accepted but not stored. A diagnosis cluster with the same attributes is already stored in the RAPS database”)
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PAYMENT PROCESS
Submission Requirements1. Must report data at least once per enrollee in the
data collection period;2. Must submit data at least quarterly;3. Submit quarterly submission that represent
approximately one-fourth of the data that will be submitted during the data collection period.
Note: In order to detect data collection and
submissions problems early, CMS recommends that MA organizations submit more frequently than quarterly.
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PAYMENT PROCESS
December, 2008 Payment Adjustments• SHMO• Other Adjustments
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DATA VALIDATION
• Calendar Year 2007– January 2006 through December 2006
dates of service will be reviewed– Enrollee samples will include beneficiaries
who were in the selected contract from January 2006 through January 2007
– RADV Samples• Contract-specific
– Pilot– Targeted– Random
• National
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DATA VALIDATION
• Calendar Year 2007 (cont’d)– Pilot RADV (notified June 20, 2008)
• IVC review completed• SVC review is in progress
– Targeted RADV (notified Nov. 10, 2008)• CMS’ contractor, HMS, will distribute
Instructions Packet shortly• Plans will have 12 weeks to submit medical
records– Random RADV
• To be implemented after release of the Instructions Packet
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DATA VALIDATION
• Calendar Year 2007 (cont’d)– National RADV (notified on Dec. 3, 2008)
• Under the Improper Payments and Information Act (IPIA), CMS must annually measure and report the Part C payment error rate
– CMS recently completed its first analysis, reporting a 10.6 percent Part C national error rate for payment year 2006
– CMS will report a Part C payment error rate for 2007 at the end of fiscal year 2009
– Request plans’ best efforts to assist in correcting and improving payment error
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DATA VALIDATION
• Calendar Year 2007 (cont’d)– National RADV (cont’d)
• Contact Information Sheet was updated to include mailing address for Primary Contact
• Instructions were distributed by traceable carrier to Primary Contact on Dec. 10, 2008
• Teleconference for plans in this sample is scheduled for Dec. 17, 2008 (2-4 p.m., Eastern)
• Plans may submit medical records via VPN, electronic media (e.g., USB, CD), fax, or hardcopy
• Deadline for medical record submission is Feb. 27, 2009
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OPERATIONS
• CSSC Operations Holiday Closings:
- Wednesday, December 24th - Thursday, December 25th - Thursday, January 1st
• Please note: the Front-End Risk Adjustment System (FERAS) will be available during this time for RAPS submissions.
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CSSC Operations Reminder
Submission Deadline• The final submission deadline for
claims with dates of service 01/01/07 through 12/31/07 is 01/31/09.
• Submit all outstanding claims.• Research errors, make possible
corrections, and resubmit corrected data.
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TECHNICAL ASSISTANCE UPDATES
Next User Group MeetingJanuary 21, 2009
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RESOURCES
• Sean Creighton (Director, Division Risk Adjustment Operations) sean.creighton@cms.hhs.gov
• Henry Thomas (Training, Project Officer) henry.thomas@cms.hhs.gov
• Louis Johnson (FERAS,GTL) louis.johnson@cms.hhs.gov
• Lateefah Hughes (RADV) lateefah.hughes@cms.hhs.gov
• LTC www.tarsc.info• CSSC www.csscoperations.com
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