December 1, 2015 CMS & HHS Risk Adjustment 101
December 1, 2015 CMS & HHS Risk Adjustment 101
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CMS&HHSRiskAdjustment101 Risk Adjustment Academy:
The cornerstones
of risk adjustment
December 1, 2015Doubletree by Hilton, North Miami, FL
CourseDevelopmentandContributors• Brian Boyce, BSHS, CPC, CPC‐I, Chief Executive Officer and Managing Consultant,
ionHealthcare, LLC
• Kameron Gifford, CPC and Chief Executive Officer, Empirical Risk Management
• Richard Lieberman, Chief Data Scientist (aka "Mad Scientist") at Mile High Healthcare Analytics
• John Murphy, Principal, Risk Adjustment Consulting
• Contributors Also Include:
• Tim Buxton, Episource
• Stacey Hernandez, SCAN Health Plan
• Tam Pham, Peak Health Solutions
• Jimmy Liu, Altegra Health
• Michele Miller, Centauri Health Solutions
FacultyforDecember1,2015:
John Murphy, Principal,
RISK ADJUSTMENT CONSULTINGJohn has worked on some of the most challenging issues in the business of health care. His 20 years of experienceincludes roles as Board Member of Bayside Community Health Center in RI; Manager of Analytics at New England QualityCare (NEQCA), Manager of Risk Operations at Tufts Medicare Preferred, and Director of Contract Settlement and Analysisat Blue Cross Blue Shield of Massachusetts. As a Director at Blue Cross Blue Shield MA, he provided the key analytics tosupport a new risk adjusted contracting model with academic medical centers. He also worked with the Senior Scientistat the leading risk adjustment and predictive modeling firm to educate key leaders and physicians on risk adjustmentfundamentals and applications. In 2008, he was recruited back to Tufts Health Plan to manage the risk operations at theirMedicare Advantage plan. He worked directly with senior executives in developing and implementing risk optimizationand mitigation strategies. His experience there included operational oversight for both a National & Targeted RADVAudit. His areas of expertise include government risk adjustment models, both Medicare and Exchange, and othercommercial risk adjustment models. Beginning in 2015, Risk Adjustment Consulting is also offering a suite of strategicand operational consulting services designed for provider organizations to successfully make the transition to risk andvalue based contract models.
FacultyforDecember1,2015:
Tara Russo, Vice President of Medicare Risk Adjustment and HEDIS Quality Initiatives ISLAND DOCTORSTara works for Island Doctors, a provider organization based in St. Augustine,Florida, that operates 14 wholly‐owned offices in Clay, Duval, Saint Johns, Flagler,Putnam and Volusia counties, as well as manage a network of 32 affiliate providersthroughout these six counties and around the Orlando area.Prior to her current role, Tara previously worked as a financial analyst for Humana,Florida Hospital and Visiting Nurse Service of New York. Earlier, she was theFinance Manager for the Department of Medicine at Memorial Sloan‐KetteringCancer Center in New York. She has a Master of Public Health from ColumbiaUniversity Mailman School of Public Health, and holds credentials as a CPC, CPMA,and CRC.
Who’sInTheRoom?Showofhandsplease…Organization Type:
• Plans, Providers, Vendors
Division/Area:
• Finance
• Coders
• Quality – HEDIS or otherwise
• Risk Adjustment
• Actuary
• Health Services
• Network Operations
• Compliance
• Other
Lines of Business:
• RA for HIX?
• RA for Medicare Advantage?
• RA for Medicaid?
RiskAdjustment:WhyDoWeDoIt?
WorkshopAgenda:December1,2015
Module 1 CMS risk adjustment models, history of payment model, CMS Bid
Module 2 – Risk Adjustment Organizational Structures and RADV
Lunch –
Module 3 – Health plan risk adjustment programs, build / buy services
Module 4 – HHS Risk Adjustment
Cocktail reception
RiskAdjustment&MedicareAdvantageAnHistoricalPerspective
TEFRA*RISKContracts:theBeginningofaLongRoadforPrivateMedicarePlans
• Healthplans paid at 95% of Average Adjusted Per Capita Cost (AAPC)
• Adjusted by Geography, Age, Sex & Original Reason for Entitlement
• Theoretically, Medicare sliced off 5% of costs automatically
• But no adjustment for healthcare conditions / burden of illness
• So, if healthplan enrolled members with less than average healthcare risk, CMS was
overpaying at 95% of average of all beneficiaries.
*Tax Equity and Fiscal Responsibility Act of 1982
PublicPolicyTowardsPrivateMedicarePlans• Original Medicare left with higher risk populations, having to pay 100% of their
healthcare costs
• These factors led to changes in federal legislation, resulting in shifting models of
payment to private Medicare plans
• Changes in plan payments yielded different levels of funding for benefits and
affected plan enrollments as a result
Medicare RiskProgramTEFRA
1976 - 1997
Medicare+Choice(M+C)
Balance Budget Act(BBA)
1997 - 2004
Medicare Advantage
MedicareModernization Act
(MMA)Passed 08/ 2003
Effective Jan 2005
Medicare AdvantageAffordable Care Act
(PPACA)Passed 03/2010
AAPCC= AverageAdjusted Per Capita
Cost95% of Medicare FFS
Costs
Frozen PaymentLevels - 2% per year
Risk AdjustedPayments
at 114% of MedicareFFS (weighted
average by county)
Risk AdjustedPayments Dropping to100% Medicare FFSweighted average bycounty 2012 to 2018
Original Medicare got bad risk?
Federal GovernmentMistrusting Health Plans.
Created New Product Types:PFFS, LPPOs, RPPOs, PACE, MSA, Demos
1999 PenetrationMedicare Population =
18%6.9 Million Enrolled
2012 PenetrationMedicare Population =
27%13.1 Million Enrolled
2004 PenetrationMedicare Population =
13%5.3 Million Enrolled
2004 PenetrationMedicare Population =
13%5.3 Million Enrolled
Created Private Part DPlans.
Revival of MedicareHealth Plan Movement
Recovered ExcessPayment.
Introduced Pay forPerformance
(Medicare Stars)
Private Medicare Plans History Illustrates Evolution
Payment to Plans
Payment year MA plans Evercare* SHMO* PACE and dual demonstrations*
risk /demographic risk /demographic risk /demographic risk /demographic 2000-2003 10% risk/90% 0% / 100% 0% / 100% 0% / 100%2004 30% risk/70% 10% risk/90% 2005 50% risk/50% 30% risk/70% 2006 75% risk/25% 50% risk/50% 2007 100% risk/0% 75% risk/25% 2008 and later 100% risk/0%
Risk Adjusted payments were determined by the relative health of individual members through the presence of certain health conditions (diagnoses)
* Demonstrations
Phase‐InofRisk‐AdjustedPayments
6.9 6.86.2 5.6 5.3 5.3 5.6
6.8
8.49.7
10.5 11.111.9
13.114.4
15.716.8
NOTE: Includes MSAs, cost plans, demonstration plans, and Special Needs Plans as well as other Medicare Advantage plans.SOURCE: MPR/Kaiser Family Foundation analysis of CMS Medicare Advantage enrollment files, 2008‐2013, and MPR, “Tracking Medicare Health and Prescription Drug Plans Monthly Report,” 2001‐2007; enrollment numbers from March of the respective year, with the exception of 2006, which is from April.
Total Medicare Private Health Plan Enrollment, 1999‐2015
Inmillions:
% of MedicareBeneficiaries
18% 17% 15% 14% 13% 13% 13% 16% 19% 22% 23% 24% 25% 27% 28%
MACodingAdjustment
Beginning in 2010, CMS instituted a separate adjustment to the Part C risk scores to account for differential coding patterns between MA and FFS.
Adjustment for MA Coding Pattern Differences: CMS will implement an MA coding pattern difference adjustment of 5.41 percent for payment year 2016 (the statutory minimum).
The goal of the MA coding adjustment is to maintain MA risk scores at the level theywould be if MA plans coded similarly to FFS providers (not necessarily a 1.0 average).
CMSPaymentModelOverview
So,WhatIsCMSRiskAdjustment?
As defined by CMS: • Risk adjustment predicts (or explains) the future healthcare expenditures of individuals based on diagnoses and demographics.
Age, Sex and
OREC*
Health Status
Adjusts Future Payment to Plan
*OREC = Original Reason for Entitlement Code ( old age and survivors insurance, disability insurance benefits, end stage renal disease, or combinations)
CMSRiskAdjustmentOverview
What is Risk Adjustment?
• CMS reimbursement methodology to Medicare Advantage Organizations
• A method used to adjust contract bidding and payment based on the health status and demographic characteristics of an enrollee
How is it determined?
• CMS calculates a risk factor for a member based on
• Demographics (age/sex)
• chronic conditions (diagnoses)
Why is it used?
• Reduces CMS financial exposure by paying based on the risk of healthcare required for the conditions of the enrollees
• Offers access, quality, protection for beneficiaries, reduces adverse selection, etc.
• Prospective‐Uses diagnosis as a measure of health status
GeneralMethodologyofCMSRiskAdjustment
Risk adjustment methodology
relies on enrollee diagnoses, as
specified by the ICD‐9‐CM*
guidelines to prospectively
adjust capitation payments for a
given enrollee based on the
health status of the enrollee.
Diagnosis codes submitted by
providers to MA organizations
Are used to determine
beneficiary risk scores,
Which in turn determine the risk‐adjusted
reimbursement.* International Classification of Disease, Ninth Revision Clinical Modification [shifting to ICD‐10 CM in October 2015]
PurposeofCMSRiskAdjustment
Allows healthplans to be paid for the actual risk of the beneficiaries they enroll
Accounts for differences in expected costs due to burden of illness (usually chronic conditions)
Adjusts annual MA contract bidding to CMS and CMS payment based on health status and demographics
Risk scores measure individual beneficiary’s relative risk, and risk scores adjust payments for expected expenditures
Allows CMS to use standardized bids as base payments to MA plans
• Each Medicare Advantage member is assigned a risk score based on their diagnoses and demographic criteria which calculates their costs/payments in a given year
• Conditions must be submitted annually, particularly chronic conditions
• ~ 3,000 ICD‐9 Diagnostic codes are grouped into ~70 Hierarchical
Condition Categories (HCCs)
• Model includes factors for age/sex, special status and HCC scores.
• HCCs are generally additive with hierarchies and disease interactions
Diagnoses‐>HCCs‐>CMSRiskScores
Example:
• A 1.0 risk score represents average annual Medicare costs for an
individual of $7,463, for illustration purposes.
• Higher than 1.0 means the individual is likely to incur costs higher
than $7,463, less than 1.0 means the individual will incur costs less
than $7,463.
• A risk score of 1.5 means expected costs of $11,195. (e.g. 50% more
expensive than the average score. $7,463*1.50)
CMSRiskScoreExample
PartCRiskAdjustmentModelforPaymentYear2016
First step is to calculate members’ scores . CMS has
fully shifted to the new version of the model known as V22 or
the 2014 model.
Each risk score is adjusted with the PY 2016
normalization factor for each payment year.
The risk score is also adjusted with the MA coding
adjustment factor.
Hierarchical Categories
• Families or hierarchical groups/categories are used in risk adjustment
• More severe or complicated illnesses (by ICD code) in the family or hierarchy will trump all others in the
category or family
• Sometimes codes which are trumped by others from a medical management perspective (Part C) may still
carry value from a prescription drug perspective (Part D)
• This leads to a strong need for coders to always code diagnoses to their highest specificity so that all
current diagnoses are accounted for each encounter
• ICD guidelines instruct coders to code for a principal diagnosis, but also all other comorbidities during
each encounter23
Hierarchical Categories in the CMS HCC Model
24
2014 Hierarchical Categories in the HCC Model
Infection BloodCerebrovascular
DiseaseComplications
Neoplasm Substance Abuse Vascular Transplant
Diabetes Psychiatric Lung Openings
Metabolic Spinal Eye Amputation
Liver Neurological Kidney Disease Interactions
Gastrointestinal Arrest Skin Disability Status
Musculoskeletal Heart Injury
CapturingCompleteDiagnosticData?
Ideal
Reality
• Industry billing has yet to fully evolve from a FFS model to a diagnosis model –provider payment based on Procedure Codes, not Diagnostic Codes
• Medical chart documentation often does not meet CMS requirements, which are more rigorous than standard practice
– > 30% of coded conditions are not supported in charts– > 40% of existing conditions are not reported through claims or
encounter data reporting
• Requirements for ICD‐9 codes to count for risk adjustment:• Face‐to‐face encounter • Only certain sources are allowable, e.g. radiology and labs are excluded• Documentation in the medical record must meet coding standards
RATheoryMeetsReality
• Physicians relying on FFS payment, bill services based on CPT procedure codes. ICD codes are minimally used only to agree with the procedures, not to be comprehensive or to highest level of accuracy
• However, CMS assigns plan payments for patients based on risk (not as reimbursement of services)
• Higher Specificity ICD-codes better define financial risk of a managed population
• 402.10 rather than 401.1
• 250.40 rather than 250.00
• ICD-9 Specificity allocates expected expenditures for the managed population
• However, CMS intends to pay only for those health conditions that are being managed, not ones that are present but not managed
CodingforRiskvs.FFSCodingforReimbursement
Documentation&CodingAffectReimbursement
CMSRiskAdjustmentModelVariations
InstitutionalHCCVersions
ESRDNew
Enrollees
RxHCCDisabled
TwoMedicareAdvantageHCCModels
Part C
CMS‐HCC
Demographic Risk Model
Part D
CMS‐RxHCC
Demographic Risk Model
TheCMSHCCModelsareEver‐Changing• The original DCG/HCC model in 2000 identified 804 costly diagnosis groups, mapped to 189 HCC codes
• Created a reporting model for reimbursement based on ICD codes within families of conditions. (Hierarchal Categories)• There are 2,944 ICD codes carrying Part C (i.e., Parts A and B) HCC value (over 3,000 in 2004)• There are 1,475 ICD codes carrying Part D (Rx) HCC value (over 3,000 in 2004)• Overlap: 978 ICD codes carry both Part C and Part D HCC value (~ 1500 in 2004)
• In 2014, the CMS‐HHC (Part C) model was heavily revised to create V22• Updated the data years used to recalibrate the model• Clinical revision of the diagnoses included in the model
• The CKD (Chronic Kidney Disease) story
• The industry reaction to this new version was so strong that CMS used a blended model in 2014 (mixing values from 2013 model and 2014 model)
• The CMS‐RxHCC (Part D) was also slightly revised in 2014
VariationswithinCMS‐HCC(PartC)Model
Established Members
Demographic Factors
Male / Female Age
Medicaid & Disabled Status
Originally Disabled
Risk Factor (HCC)
Community or Institutional
‘New Enrollees’
Demographic Factors
Male / Female Age
Medicaid Status
Disabled or Not
Risk Factor (HCC)
New enrollees are not included in the HCC model
as there is no history.
AMember’sRAF(RiskAdjustmentFactor)istheSumoftheirDemographicFactor+theCoefficientofAnyHCCs
Established Member
• RAF= Demographic Factor + HCCa+HCCb+ HCCc +…..
New Enrollee
• RAF = Demographic Factor only
NewEnrolleeExampleBen Beneficiary turned 65 in October of 2014 and became entitledto Medicare. Ben opted to enroll in a Part C plan.
He will be a “New Enrollee” until the year? risk score modelrun.
(see table on next slide)
Model Run Dates of Service Ben’s Status Reason
2015 Initial 7/1/14 – 6/30/14 New Enrollee Does not have 12 months of Medicare Part B entitlement
2015 Mid‐year 1/1/14 – 12/31/14 New Enrollee Does not have 12 months of Medicare Part B entitlement
2015 Final 1/1/14 – 12/31/14 New Enrollee Does not have 12 months of Medicare Part B entitlement
2016 Initial 7/1/14 – 6/30/15 New Enrollee Does not have 12 months of Medicare Part B entitlement
2016 Mid‐year 1/1/15 – 12/31/15 Full Risk Has 12 months of Medicare Part B entitlement
New Beneficiary to Full Risk Score Example
TheGoodNews!
All of these Demographic Factors and HCC Coefficients are in easy to use tables
CMS‐RxHCC– PrescriptionDrugRiskAdjustment• Part D (Prescription Drug Benefit) was created as the result of the 2003 MMA (Medicare Modernization Act)
• Basic “HCC” approach used to create the RxHCC Model; similar to Part C
• Model relies on certain conditions (diagnoses) to predict the prescription cost of those conditions.
• Example:
• Part C Model HCC 18 “Diabetes with Chronic Complications” has a value of 0.378
• Part D Model RxHCC 14 “Diabetes with Complications” has a value of 0.276
• If the Plan covers Parts C & D, a member with Diabetes with Complications would get an additional (0.378 * Part C bid rate + 0.276* Part D bid rate)
VariationswithinCMS‐RxHCC(PartD)Model
Established Members
Demographic Factors
Male / Female Age
Community – Low Income
Community – Non Low income
Institutional
Risk Factor (HCC)
Community – Low Income
Community – Non Low income
Institutional
‘New Enrollees’
Demographic Factors
Community –’Income’
Originally Disabled or not
ESRD or not
Institutional
ESRD or Not
Risk Factor (HCC)
New enrollees are not included in the HCC model as there is no
history.
AnnualCMSBid
CMSPlanPaymentMethodology
County Level Base Payment
Relative Factors
Risk Adjustment
Factor
The Medicare Stars Payment
Factor
AnnualCMSCalendar
Published in the Annual Rate Announcement
The calendar provides important operational dates for all organizations such as the date CMS bids are due, the date that organizations must inform CMS of their contract non‐renewal, and dates for beneficiary mailings.
January 1, 2016Plan Benefit Period Begins
January 1 –February 14, 2016Annual 45‐Day Medicare Advantage Disenrollment Period (MADP).
Early January 2016Release of CY 2017 MAO/MA‐PD/PDP/SAE/EGWP applications.
Mid‐January, 2016Industry training on CY 2017 applications.
Late February 2016Applications due for CY 2017.
PartCBidandReviewProcess• By law, the Part C basic plan bid is the total revenue needed to offer original Medicare (Part A & Part B) benefits:
to enrollees who live in a specific service area (one or more counties)
who have a certain level of average risk expected by the MAO
& assuming the plan will charge cost sharing equivalent to FFS
• The law establishes rules for determining plan benchmarks – the upper limit on what the gov’t will pay for each enrollee.
• The law requires CMS to compare the plan basic bid to the plan benchmark to determine whether the plan must charge an enrollee premium or can offer supplemental benefits at a reduced price.
• For MA plans with bids below benchmarks, 75% of the difference (“rebate”) must fund coverage of supplemental benefits, e.g. reduction in FFS‐level cost sharing and/or coverage of additional non‐Medicare covered benefits.
PartCBidandReviewProcess
CMS reviews each bid for actuarial soundness
Ensures that each bid reflects costs of
providing proposed benefit package
Risk adjustment used to standardize bids to determine what CMS’ payment rate will be to the plan for each
enrollee.
Risk Adjustment allows direct
comparison of bids based on populations with different health status and other characteristics
Risk adjustment is also used to pay more
accurately by adjusting the monthly capitated bid‐based payments for enrollee health
status
SimplifiedExampleIllustratingUseofRiskAdjustmentinBidding
Plan derived costs for benefit package = $1,000
Plan estimated risk score for population = 1.25
Standardized plan bid = $800 ($1,000/1.25)
Plan actual risk score based on enrollment =
1.5
Risk adjusted plan payment = standardized plan bid * actual risk
score = $1,200 ($800*1.5)
Courtesy of Jeremy Walsleben, Kaiser Permanente, Colorado
Normalization
Normalization adjusts for growth in risk scores year
after year.
Reasons for this include population trends and
diagnostic coding between model estimation and
payment year.
Normalization Factor
CMS uses a standard of five years of data in the normalization trend.
Each year, CMS drops the earliest year and adds a new year of risk scores to the trend data to create the five‐year dataset.
By using a standard number of years, CMS calculates risk score trends based on recent trends in coding, while maintaining stability in the year to year trends.
Normalization factors are downward adjustments to risk scores and are applied to risk scores when they are calculated.
Risk scores on the MMR are always normalized.
Factors are announced in the Annual Rate Announcement
TypicalHealthPlanRiskAdjustmentProgramCMSRequirements,DataSubmission,Reports,Etc.
MAPlanSponsorRequirements
Ensure the accuracy and integrity of risk adjustment data submitted to CMS.
All diagnosis codes submitted must be documented in the medical record and must be documented as a result of a face to face visit.
The diagnosis must be coded according to ICD‐9‐CM / ICD‐10‐CM Guidelines for Coding and Reporting.
MAPlanSponsorRequirements
Part B only Beneficiaries
•Plan sponsor must submit ICD‐9‐CM Codes / ICD‐10‐CM under the same rules as a beneficiary with both Parts A and B.
• Submit all ICD‐9 –CM codes for Part A services provided under a non‐Medicare contract.
Risk Adjustment Reports
•Receive and reconcile CMS Risk Adjustment Reports in a timely manner.
•Plan sponsors must track their submission and deletion of ICD‐9‐CM Codes / ICD‐10‐CM
• diagnosis codes on an ongoing basis.
Recalculations
•Once CMS calculates the final risk scores for a payment year, plan sponsors may request a recalculation of payment upon discovering the submission of inaccurate ICD‐9‐CM Codes / ICD‐10‐CM
• diagnosis codes that CMS used to calculate a final risk score for a previous payment year and that had an impact on the final payment.
TheCMSMandate
The goal of complete and accurate documentation in progress notes is to help CMS evaluate the costs
of taking care of the patient and pay Medicare Advantage plans accordingly.
Thorough documentation promotes Continuity of Care!
Medicare’s guidelines state,” Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment”.
CMSGuidanceforMedicareRA
RAPS Participant Guide, section 6.4:
“Standard ICD‐9‐CM coding practices support the HCC model. In all
cases, the documentation must support the code selected and
substantiate that the proper coding guidelines were followed…. Upcoding
or changing diagnoses to obtain higher reimbursement is fraudulent.”
CMSGuidanceforMedicareRA
RAPS Participant Guide, section 6.4:
• “Physicians should code all documented conditions that
co‐exist at the time of the encounter/visit, and require
or affect patient care treatment or management. [sic]
• “Do not code conditions that were previously treated
and no longer exist.”
OneExampleofCMSRiskAdjustmentFunctionalOrganization
Operations Vendor Management Coding Program
Management Provider Engagement Outcomes Management
Analytics & Reporting
Data Infrastructure Quality Controls Reporting
Operations Network Internal
CMS Submissions (RAPS/EDPS) RAPS/EDPS reconciliation
Quality Assurance
PCP Claims Validation Vendor Coding Oversight Coding Education RADV Response Policy & Procedure
Oversight
Objective: Achieve accurate Risk Adjustment Factor (RAF) with complete documentation
Interfaces with Other Functional Departments:
• Quality• Care Mgt.
• Provider Relations• Stars
• IT• Pharmacy• Finance• Actuarial
WhatisRAPS?
• RAPS is the CMS Risk Adjustment Processing System through which risk adjustment data are processed.
After the data submitted by Medicare Advantage (MA) organizations passes the checks in the Front‐End Risk Adjustment System (FERAS), the data is sent to the CMS data center for RAPS processing.
RAPS performs complete editing of all detail records which are then stored in the RAPS database.
As a precautionary measure, RAPS performs balancing checks to ensure that the complete file was received from FERAS prior to editing data.
The RAPS system performs editing on the detail record transactions.
Data elements edited include HIC Number, Provider Type, From Date, Through Date, and Diagnosis Code.
If Date of Birth is submitted, RAPS also performs an edit on that field.
CMSRAPSModelRunPaymentperiods&datesofserviceincludedinmodelrun
• Contracts should recognize the connection between the model runs, the dates of service, and changes in risk score for initial, mid‐year, and final reconciliation.
PY2015 Initial Model Run {Payment 1/1/15 – 6/30/15}
DOS: 7/1/2013 – 6/30/2014
PY 2015 Mid‐year Model Run {Payment 7/1/15 – 12/31/15}
DOS: 1/1/2014 – 12/31/2014
PY2015 Final Model Run {Lump sum payment ~8/2016}
DOS: 1/1/2014 – 12/31/2014
Each year has 3 Model Runs:
In order for data to be included in the model run, MAorganizations must meet three submission deadlines eachyear: the first Friday in September, the first Friday in March,and January 31 after the payment year.
CMSSubmission1
MAO
The physician’s office or hospital codes claim and submits data to
MAO.
2
RAPSFormat
MAO sends diagnosis clusters in RAPS format to
Front‐End Risk Adjustment System
(FERAS) at least quarterly.
3
FERAS
Data goes to FERAS for processing where file‐level data, batch‐level data, and first and last detail records are
checked.
SubmittedMRADataElements
• MA organizations must collect certain data elements from the sources (providers/physicians) of risk adjustment data.
• The five (5) minimum data elements that must be collected and submitted are:
HIC (Health Insurance Claim) number,
Provider Type
From Date of Services,
Through Date of Services, and
Diagnosis Code
MRADataSubmissionTimeline
Payment Year
Model Run
Dates of Service Timeframe
2016 Initial 7/1/2014 – 6/30/2015 September 2015
2016 Mid‐year 1/1/2015 – 12/31/2015 March 2016
2016 Final 1/1/2015 – 12/31/2015 January 2017
RAPSEditsRules• The RAPS editing process takes place in four logical stages.
Stage 1‐ Field Validity and Integrity Edits
Stage 2 ‐ Field‐to‐Field Edits
Stage 3 ‐Eligibility Edits
Stage 4 ‐Diagnosis Code Edits
Risk Adjustment Processing System:
• Mechanism for submitting diagnoses to CMS
• Minimum Risk Adjustment Data Elements
• Diagnosis Code
• Health Insurance Claim (HIC) Number
• From Date
• Through Date
• Provider Type
RAPS Return File:
• Contains all submitted transactions to CMS
• CMS’s acknowledgement of what has been
accepted and what has been submitted in error
RAPSReconciliation
Filtering for RAPS SubmissionsMA organizations are required to filter risk adjustment data submitted to RAPS toensure it only comes from acceptable hospital inpatient, hospital outpatient, andphysician provider types.
Hospital inpatient data require admission and discharge dates of service from appropriatefacilities.
Outpatient data require diagnoses from appropriate facilities and covered services
contained on the CMS covered outpatient listings.
Physician data require visits with a professional listed on the CMS specialty list.
Diagnoses must result from a face‐to‐face encounter with an acceptable provider.
MRAReports• Plans are required to comply with CMS requirements to submit accurate data in a timely manner, which includes submitting diagnoses, meeting the quarterly submission requirement, and not submitting duplicate diagnosis clusters.
• Plans attest when signing EDI Agreements that they will, to the best of their knowledge, information, and belief, submit risk adjustment data that are accurate, complete, and truthful.
• Non‐compliance may result in CMS restricting future risk adjustment submissions by an MA organization, so it is important for plans to understand the types of errors that are identified.
When a Medicare Advantage (MA) organization submits a RAPS file to FERAS, FERAS performs the format and integrity checks.
MAO Deletion Responsibilities
• MA organizations may submit corrections and deletions on the same record or in the same file.
Duplicate deletes in the same record on the same day cause system problems.
Remember:
Only accepted diagnosis clusters may be deleted.Erroneously submitted clusters must be deleted.
Incorrect clusters must be deletedfrom the system before correct
cluster information can be added.
DuplicateDiagnosisClusters
• What if a member goes to the doctor on separate occasions and receives the same diagnosis each time.
• Since the plan submits RAPS records every month, is the diagnosis stored each time a RAPS record is sent/received by CMS, or only the first time the diagnosis cluster was submitted?
Each of the clusters would be unique diagnosis clusters because they have different dates of service. (Duplicate diagnosis clusters are those that have the same HIC, from and through dates of service, diagnosis code, and provider type). Therefore, they will appear on the report in the counts for total stored. The diagnosis would be stored, but later de‐duped when the model was run.
Can diagnosis clusters be duplicated over time?
Plans may contact CSSC at 1‐877‐534‐CSSC for assistance locating the files that triggered the duplicate diagnosis cluster.
RAPS Management Reports
Report Details
RAPS Monthly Plan Activity Report
• Provides monthly summary of the status of submissions by submitter ID and plan number• Report layout• Available for download the second business day of the month, in months with activity
RAPS Cumulative Plan Activity Report
• Provides cumulative summary of the status of submissions by submitter ID and plan number• Report layout• Available for download the second business day of the month, in months with activity
RAPS Monthly Error Frequency Report
• Provides monthly summary of all errors associated with files submitted in test and production• Report layout• Available for download the second business day of the month
RAPS Quarterly Error Frequency Report
• Provides a quarterly summary of all errors on all file submissions within the 3‐month quarter• Report layout• Available for download the second business day of the month following each quarter
AnalyzingRAPSManagementReports
• When analyzing the monthly RAPS management reports, CMS urges MA organizations to consider the following questions:
“Is my organization collecting enough
data from physicians and providers?”
“Is my organization collecting the correct data from physicians and providers?”
“Are external issues affecting data collection?”
“Are internal processes supporting data submissions?”
Payment
• The Risk Adjustment Model is
lagged, meaning 2015 data
(diagnoses) drives 2016
revenue
• The graphic to the right
displays the submission
deadlines for risk adjustment
data to CMS
• Initial and Final Submission
Deadlines are commonly
referred to as “sweep dates”
CMSEDPSOverview
Encounter Data Processing System
• New system CMS is currently implementing.
• Captures more claims and demographic data than
the RAPS system and is designed to improve the
accuracy of risk adjustment payments and member
RAF scores
• Encounter data can be used to develop and calibrate
CMS‐HCC risk adjustment models
• CMS can use the data for calculating Medicare
Disproportionate Share Hospital (DSH) percentages,
Medicare coverage purposes, and quality review and
improvement activities
CMSEDPSvs.RAPS
• Major differences between the EDPS and the current RAPS System. Data collection changes from the 5 RAPS elements to ALL elements of a HIPPA standard 5010 format 837.
Timing of required data submission changes from quarterly intervals to monthly.
Increase in volume of data collected, edited, and stored.
For payment year 2016 (2015 dates of service) RAPS and EDPS will run in parallel with 90% of the payment calculated from RAPS and 10% calculated by EDPS.
This ratio is very likely to focus more on EDPS than on RAPS in the coming years
CMSEncounterData System Process Flow
MAO and Other EntitiesEncounter Data
Front-End System(EDFES)
Encounter DataProcessing System
(EDPS)
EDPPS
EDIPPS
EDDPPS
Subsystems of the EDPS
EODS
Risk Adjustment System (RAS)C M S Medicare Advantage
Prescript ion Drug System(MARx)
OR
OR
MAReports OverviewType Report
FERAS FERAS Response
RAPS Transaction RAPS Return File
RAPS Transaction RAPS Transaction Error Report
RAPS Transaction RAPS Transaction Summary Report
RAPS Transaction RAPS Duplicate Diagnosis Cluster Report
RAPS Management RAPS Monthly Plan Activity Report
RAPS Cumulative Plan Activity Report
RAPS Monthly Error Frequency Report
RAPS Quarterly Error Frequency Report
Analytics&Reporting
• CMS provides many, many reports. A typical, well run, program will actively monitor and use
these reports to:
• Reconcile payments
• Project future revenue (recall that diagnoses excepted in current year drives next year’s
revenue)
• Core data source for analytics and external reporting (provider groups)
• Critical Information to Analyze & Develop Useful Reporting
• What HCCs (typically chronic conditions) did each member have in previous years but have not
been submitted in the current year…Dropped HCCs
• Is there a group or practice that has HCC outliers?
• 60% of Plan’s diabetic population has complications but Group A’s is only 20%
QualityAssurance
• Does the plan have a system that proactively checks that diagnoses codes submitted are
consistent with the medical record?
• CMS requires that for medical records being reviewed, past HCCs must be validated
• Coding education and oversight should be the #1 priority
• How often do the Plans’ coders find errors in the medical records?
• How often are the Plans’ coders wrong? Is there independent monitoring of these coders?
• If a provider or provider group only has uncomplicated diabetics; do their medical records
confirm that? Are they documenting complications but using the ‘easy or familiar’ code? Is
there a process to identify these cases and provide interventions?
• Policies & Procedures should be developed, approved, disseminated, and followed.
RADVCMSRiskAdjustmentDataValidationProgram
Purpose
CMS’ RADV audit initiative is the Agency’s primary strategy to
address the national payment error rate for the MA program, which is was estimated to be 11 percent for
FY 2011.
In addition to recovery of overpayments through RADV
audits, CMS also expects that these contract‐level audits will have a
sentinel effect on the quality of risk adjustment data submitted for payment by MA organizations.
• RADV validates diagnoses submitted for payment.
• RADV is a corrective action to help reduce the Part C error rate. ‐ Each year CMS
reports a National Payment Error Estimate to comply with the Improper Payments
Elimination and Recovery Act (IPERA) of 2010
• CMS expects that RADV will have a sentinel effect on quality of risk
adjustment data submitted for payment going forward.
CMS Risk Adjustment Data Validation (RADV) Overview
MAO‐submitted risk adjustment diagnoses must be:
• Based on clinical medical record documentation from a face‐to‐face encounter
(patient and provider)
• Coded in accordance with the ICD‐9‐CM Guidelines for Coding and Reporting
• Assigned based on dates of service within the data collection period
• Submitted to the MA contracts by acceptable: RA provider type
• RA provider data source
RADVVerifiesDiagnosesSubmittedforPayment
CMSRADVMethodology
“Notice of Final Payment Error Calculation Methodology for Part C Medicare Advantage Risk Adjustment Data Validation Contract‐Level Audits” was published on February 24, 2012
On December 21, 2010 the Centers for Medicare and Medicaid Services (CMS) posted on its website the “Medicare Advantage Risk Adjustment Data Validation (RADV) Notice of Payment Error Calculation Methodology for Part C Organizations Selected for RADV Audit – Request for Comment”.
CMSRADVAudits
• Section 1853(a)(3) of the Social Security Act requires that CMS risk adjust payments to Medicare Advantage (MA) organizations.
RADV audits determine whether the diagnosis codes submitted by MA organizations can be validated
by supporting medical record documentation.
This medical record documentation must meet certain criteria and standards specified in
RADV materials that CMS provides to audited contracts.
Diagnoses that cannot be validated contribute to a payment
error rate.
EstimatingMAPaymentError
National RADV
• Estimates national (Part C) payment error
• Includes both continuously and noncontinuously enrolled beneficiaries in eligible contracts
• Small sample of members (5‐10)
• Estimates national (Part C) payment error
• Includes both continuously and noncontinuously enrolled beneficiaries in eligible contracts
• Small sample of members (5‐10)
Contract RADV
• Estimates contract level payment error
• Contracts randomly selected from among all active contracts
• Only continuously enrolled beneficiaries
• Includes 201 members
• Estimates contract level payment error
• Contracts randomly selected from among all active contracts
• Only continuously enrolled beneficiaries
• Includes 201 members
SamplingFrameforCMSRADV• First, CMS identifies all beneficiaries under each MA contract who are “RADV‐eligible” because they meet the following criteria:
Enrolled in an MA contract (H‐number, E‐number, or R‐number) in January of the payment year— based on CMS' monthly member enrollment files;
Continuously enrolled in the same MA contract (as identified in step (1) above) from January of the data collection year through January of the payment year;
Non‐End Stage Renal Disease (non‐ESRD) status from January of the data collection year through January of the payment year;
Non‐hospice status from January of the data collection year through January of the payment year;
Enrolled in Medicare Part B coverage for all 12 months during the data collection year (i.e., defined as full risk enrollees for risk adjusted payment); and
Had at least one risk adjustment diagnosis (ICD‐9‐CM code) submitted during the data collection year that led to at least one CMS‐Hierarchical Condition Category (HCC) assignment for the payment year.
SampleSizeandStrataforCMSRADV
• Next, CMS selects a sample of beneficiaries from each contract’s cohort of RADV‐eligible enrollees. Enrollee‐based stratification will be used in the process of sampling enrollees.
In order to derive the strata, the RADV‐eligible enrollees in each contract will be ranked from lowest to highest based on their community risk score.
Highest
Middle
Lowest
20167
67
67
MAPaymentErrorCalculationEnrollee‐level Payment Error Calculation
CMS will calculate each contract’s payment error based on the validation results.
For each sampled enrollee, the RADV‐corrected risk score and corrected payment will be calculated based on the CMS‐ HCCs that are supported by RADV medical record review findings for the enrollee.
Enrollee‐level payment errors will be defined as the difference between the original payment and the RADV‐corrected payment (per member per month).
The payment error for each enrollee will be either positive(representing a net overpayment), or negative (representing a net underpayment).
An annual payment error amount will be calculated for each sampled enrollee based on the number of months the person was enrolled in the selected MA contract (and was not in ESRD or hospice status) during the payment year.
• Risk Adjustment Data Validation
• Purpose: to ensure risk adjusted payment integrity and accuracy
• Method: Review of hospital (inpatient & outpatient) and physician
medical records
• Objectives:
• Verify enrollee CMS‐HCCs by submitting “best medical record”
• Identify risk adjustment discrepancies
• Calculate enrollee‐level payment error
• Estimate national and contract‐level payment errors
• Implement contract‐level payment adjustments
CMSAudits
This checklist list was provided to plans involved in the calendar year (CY) 2009 and CY 2010 national RADV audits. This list may help to determine a record’s suitability for Risk Adjustment Data Validation (RADV). Any items checked “no” may indicate that the record will not support a CMS-HCC.
1. Is the record for the correct enrollee? 2. Is the record from the correct calendar year for the payment year being audited (i.e., for audits of 2011 payments,
validating records should be from calendar year 2010) 3. Is the date of service present for the face to face visit? 4. Is the record legible? 5. Is the record from a valid provider type? (Hospital inpatient, hospital outpatient/ physician) 6. Are there valid credentials and/or is there a valid physician specialty documented on the record? 7. Does the record contain a signature from an acceptable type of physician specialist? 8. If the outpatient/physician record does not contain a valid credential and/or signature, is there a completed CMS-
Generated Attestation for this date of service? 9. Is there a diagnosis on the record? 10. Does the diagnosis support an HCC? 11. Does the diagnosis support the requested HCC?
CMSRiskAdjustmentDataValidation(RADV)MedicalRecordChecklistandGuidance
When submitting a record for RADV, consider the following:
• If the condition warrants an inpatient hospitalization, the HCC may be supported by an inpatient record. Examples of such conditions may include septicemia, cerebral hemorrhage, cardio respiratory failure, and shock. For these conditions, an inpatient record, a stand‐alone inpatient consultation record, or a stand‐alone discharge summary may be appropriate for submission.
• When possible, obtain a record from the specialist treating the condition, e.g. an oncologist for a cancer diagnosis. These records may be more likely to sufficiently document the condition.
• Pay special attention to cancer diagnoses. A notation indicating “history of cancer,” without an indication of current cancer treatment, may not be sufficient documentation for validation. For example, if in an attempt to validate HCC 10 (Breast, Prostate, Colorectal and Other Cancers and Tumors) a Medicare Advantage contract submits a record that indicates a patient has a history of cancer that was last treated outside the data collection year, the HCC may be not be validated.
CMSRiskAdjustmentDataValidation(RADV)MedicalRecordChecklistandGuidance(cont’d)
When submitting a record for RADV, consider the following: • When reviewing medical records, pay special attention to the problem list on electronic medical records.
Often, in certain systems, a diagnosis never drops off the list, even if the patient is no longer suffering from the condition. Conversely, the problem list may not document the HCC your MA contract submitted for payment.
• Any problem list in submitted documentation should be included and not just referenced. • Records submitted to validate HCCs that encompass additional manifestations or complications related to the
disease (e.g. HCC 15, Diabetes with Renal Manifestations or Diabetes with Peripheral Circulatory Manifestations) should include language from an acceptable physician specialist which establishes a causal link between the disease and the complication. An acceptable record that clearly defines the complication or manifestation and expressly relates it to the disease may validate the HCC. A record that does not define and link this relationship may not validate the HCC.
• If a physician or outpatient record is missing a provider’s signature and/or credentials, consider using the CMS‐Generated Attestation that was provided with your data. CMS will only consider CMS‐Generated Attestations for RADV. Minimum requirements for inpatient records state that these must contain an admission and discharge date. In addition:• inpatient records must include the signed discharge summary,• stand‐alone consultations must contain the consultation date, and • stand‐alone discharge summaries submitted as physician provider type must contain the discharge date
CMSRiskAdjustmentDataValidation(RADV)MedicalRecordChecklistandGuidance(cont’d)
FinalMAPaymentErrorCalculationMethodology
• Methodology will be applied to next round of contract level audits conducted on payment year 2011
• Extrapolation will begin with payment year 2011 • Approximately 30 contracts will be selected for audit • Contracts will be able to submit multiple medical
records per CMS‐HCC • Fee‐for‐Service Adjuster will be applied to payment
recovery amounts
CMSRiskAdjustmentDataValidation
National RADV
• Estimates national (Part C) payment error
• Includes both continuously and noncontinuously enrolled beneficiaries in eligible contracts
• Small sample of members (5‐10)
• Estimates national (Part C) payment error
• Includes both continuously and noncontinuously enrolled beneficiaries in eligible contracts
• Small sample of members (5‐10)
Contract RADV
• Estimates contract level payment error
• Contracts randomly selected from among all active contracts
• Only continuously enrolled beneficiaries
• Includes 201 members
• Estimates contract level payment error
• Contracts randomly selected from among all active contracts
• Only continuously enrolled beneficiaries
• Includes 201 members
• Effective with the CY 2011 RADV audits, CMS will allow audited MA contracts to
submit up to five medical records for each audited CMS‐HCC per enrollee.
• A CDAT management function will allow MA contracts to add, re‐order, and delete
medical records for each enrollee up until the submission deadline.
• CMS will consider individual hardship requests if an MA contract identifies the need
to submit more than five medical records per sampled CMS ‐ HCC.
CMSRADVProcess–MedicalRecordReview
ProgramManagement:OptimizingResults
TheCMSAnnual“MiracleCure”Member on December 31st Same Member on January 1st
CMS requires all HCC diagnoses to submitted each and every year the condition is present.It is of critical importance that plans ensure that members with HCC diagnoses be seen by a qualified provider and all current HCC diagnoses be evaluated and reported each year.
• Provider education and engagement
• CMS also allows plans to collect data from “alternate sources” which can
be looked at as being either Prospective or Retrospective
WhatCanbeDonetoEnsurethatAllHCCDiagnosesareCapturedEachYear?
• Initiatives taken prior to an encounter to ensure valid diagnosis codes are documented at the time of the encounter
• These include Patient Assessment Forms (PAFS) and Comprehensive Health Assessments (CHAs)
•Pros: Aids in capturing complete and accurate diagnoses at the time of the encounter
•Cons: Slow adoption
• Initiatives taken prior to an encounter to ensure valid diagnosis codes are documented at the time of the encounter
• These include Patient Assessment Forms (PAFS) and Comprehensive Health Assessments (CHAs)
•Pros: Aids in capturing complete and accurate diagnoses at the time of the encounter
•Cons: Slow adoption
Prospective
• Actions taken after the encounter has already taken place in order to ensure complete data collection
• These include Chart Reviews
• Pros: Charts relatively easy to access
• Cons: Incomplete diagnostic profile
• Actions taken after the encounter has already taken place in order to ensure complete data collection
• These include Chart Reviews
• Pros: Charts relatively easy to access
• Cons: Incomplete diagnostic profile
Retrospective
Allows plan to get a full picture of “New Enrollees” for following year payment
Provides early identification for case and disease management programs
Fairly costly to vend – Some plans will pay providers directly for a comprehensive review early in the year
CMS has tried to eliminate these over the past few years. They feel that it is used to gather HCC diagnoses only; no real health value. They are allowing it to continue provided that the results are sent to the member’s PCP.
ProspectiveAssessments
Targeting / Suspect Generation
Which members and providers to review?
Record Retrieval
How to get tens of thousands of records from providers?
Provider Engagement
Why should overworked providers help?
RetrospectiveReviews:TheCoreofRiskAdjustmentProgramManagement
RetrospectiveReviews:Targeting/SuspectGeneration
Perfect World Real World
In a perfect world, providers would correctly document,code, and submit all conditions all the time.
In the real world, documentation is flawed, incorrectdiagnosis codes are used, and many chronic conditions do not get submitted each year
RetrospectiveReviewTargeting/SuspectGeneration
Dropped HCCs – Member has been diabetic for years but no current diagnoses found
Co‐Morbidity – Member is Morbidly Obese; strong likelihood of Diabetes
Pharmacy – Member takes a drug typically used for vascular disease but no diagnosis is found
High # of HCCs – Members with many reported HCCs typically have even more that go unreported
Very Low # of HCCs – This is a population that typically have some HCCs, especially as they age. Others – Deviations of actual cost vs predicted costs; use of other risk adjustment models; outliers in frequency comparisons;
Stratification1. The ‘value’ of HCCs vary widely. Some have a weight of 2.546 and others have a
weight of 0.046. This difference represents ~$22,000 per year.
2. Aside from Dropped HCCs, where there is prior evidence, targeting new member‐conditions have varying probabilities.
• A member taking a drug that is only associated with diabetes has a high probability of having that condition.
• A member taking a drug that is used for many different conditions, including diabetes, has a lower probability of having diabetes,
3. Using information from 1 & 2 can be very helpful in selecting targets for retrospective reviews. Note that the probabilities in 2 are mostly anecdotal so while useful, it should be one of many factors in target selection.
RetrospectiveReviewRecordRetrieval
Targets associated with 2‐3 ‘best’ providers & DOS
How many targets are ‘worth’ pursuing? Declining ROI…what is the optimal target list? Provider PITA factor?
Logistically complex – poor data on provider location; should provider fax the records or will someone physically collect them; scheduling and timing; who will code all these charts; etc.
Results are a gold mine of data and information if managed well. PDFs should be easily accessible, data (typically excel) should be analyzed and reports generated
Another process CMS is not fond of. Same reason as prospective reviews…just getting HCCs. CMS now requires that retrospective reviews be done to validate submitted HCCs; if unreported HCCs are found then they can be submitted. Plans must have a process in place to meet this requirement.
RetrospectiveReviewProviderEnragementEngagement
Providers are increasingly subjected to more and more record requests:
• HEDIS
• STARS Program
• Medicare Advantage Retrospective Reviews
• HHS Risk Adjustment Retrospective reviews
• Others
There are still many small provider groups who are not using an EMR; or using one in a meaningful way.
• The staffing at many of these groups is very tight; asking them to take time to collect specific records, make copies, and fax or mail them to the plan may not be met with a positive response
Even some larger groups with integrated EMRs may rely on HIPAA to make access to the EMR difficult.
Significant planning and communication should be done to optimize providers’ response
RetrospectiveReviewProviderEngagement
• Most MA risk contracts are percent of premium deals• Group gets a majority of the CMS revenue and must cover whatever medical costs are incurred.
• They are self motivated to ensure that all HCCs are accounted for.
• That motivation does not always trickle down to the individual provider.
• The risk entities infrastructure can take on many of the critical tasks in the retrieval
• The “What’s in it for me?” Barrier• Many ways to address this; plans may try a variety of approaches to overcome this.
• Clinical – Missing conditions is not good medicine
• Competitive – Answers the whose patients are sicker question
• Fear – Almost all provider payments will be based on risk adjustment soon.
• Financial – Reimbursement for time and material
• Contractual – Providers typically have a duty to provide these records
Provider Group in a Risk Contract Provider Group with no Risk Contract
ProviderTrainingandReporting
Education on Risk Adjustment
Develop group, provider, & member level reporting on RAF
scores
Send un‐blinded, comparative reports to
provider groups
Manage the inevitable push back from the providers
This is actually a positive. Once providers accept the analytics,
the reports become a competition
Address individual questions/accusations such as “I know I have at least 15 Morbidly Obese patients” by showing the
absence of the diagnosis codes for those patients
ProviderEducationandReporting• Providers have focused on CPT codes since Hippocrates. Diagnoses codes were a distant second.
• CPT codes equaled payment
• In a perfect world, see prior slide, risk adjustment departments could be staffed by 1 FTE or less in the IT department.
• Moving toward that perfect world is an ongoing challenge but must be done. It won’t happen quickly but improvements can be made.
• Reporting that is specific to a provider, provider group, and system is most effective.
• Two insights on providers:
• They are extremely skeptical about any report from a health plan
• However, once satisfied with the validity; they tend to embrace these reports…especially those that show comparative performance
ProgramOperations• Almost all of the functions within a risk adjustment department revolve around
getting diagnoses codes that, for some reason, have not been submitted to the plan.
• A large part of this is also ensuring that a submitted diagnosis code can be validated
by the medical record. The reverse is true as well – does the documentation and
diagnosis code show the full complexity of a condition?
• If a diagnosis code is submitted that links to HCC 108 “Vascular Disease”; does
the medical record documentation fully support that? Or is it a RO or a
suspected condition?
• Does the documentation appear to support two linked conditions but is worded
in a way that the coder cannot assign the proper code?
• The next slides will show what actions are taken at specific times of the year to
optimize the correct HCCs
Operations– November&December2015• Finalizing 2014 retrospective reviews
• January 2016 is the very last time these can be submitted. Payment will be in a lump sum in
July/August 2016
• Members with dropped HCCs in 2015 must see a provider by 12/31/15
• Monthly revenue for first six months of 2016 are known, caeteris paribus.
• Based on results of the September 2015 Model run (7/1/14 – 6/30/15 DOS)
• CMS report on results of open enrollment period
• Established members staying with the plan
• Established members coming from another plan
• New enrollees coming from another plan
Operations– January&February2016
• Last push for CY2014 submission
• Selection process for New Enrollees to the plan for Prospective Assessments
• Begin Prospective Assessments
• Implement RAF (Risk Adjustment Factor) build up process
• Dropped HCCs are the biggest source of missed revenue. This process looks at all the HCCs
for each member in 2015 with the expectation that, if chronic, should be seen in 2016.
• In the early part of the year, the build up will naturally be low as members may not have
had a chance to see their provider yet
• Recall that everyone is completely health on January 1st according to CMS
Operations–March&April2016
• Complete March submission – DOS 1/1/15 – 12/31/15
• Drives monthly payment from 7/1/16 – 12/31/16
• Finalize any new interventions for 2016
• Continue Prospective Assessments
• Start analyses to develop Retrospective Review target list
• Continue tracking RAF build up
Operations–May,June,&July2016• Begin Retrospective Reviews
• Develop materials to send to targeted providers
• Logistics should be in place
• Continue RAF build up and begin intervention
• By June and July, the plan should know which members have not had a prior year HCC submitted yet.
• Contact providers who submitted members’ HCCs in 2015 as well as members’ PCPs to encourage them to get the member in to document the HCCs that are still active.
• Identify members without an E&M visit in 2016 and get them seen
• Closely monitor Retrospective Reviews until January 2017 submission!
Operations– August&September
• Continue RAF build up monitoring and interventions
• * Reconcile lump sum payment (* may be done in different area)
• Adjustments based on final 2014 submission
• Adjustments to January – June monthly payments
• These payments are based on the September submission of 7/1/14 – 6/30/15 DOS
• Adjustments to member enrollment
• Any other final adjustment to 2014
• Complete September submission – DOS 7/1/15 – 6/30/16
• Drives monthly payment for 1/1/17 – 6/30/17
• Closely monitor Retrospective Reviews until January 2017 submission!
CommonMisconceptions
Trusting clinicians (or software) to code correctly
Ignoring ICD‐10‐CM as a resource for ICD‐9‐CM coding
Expecting non‐RA coders to code accurately for RA
Delaying the implementation of a CDI program
Underestimating the importance of the Official Guidelines to Coding and Reporting
Overlooking the need to audit coders regularly
Coding diseases and conditions without support
Keeping references and resources current
Assuming Coding Clinic guidance is only for inpatient coders
Believing your education is complete
TipsforClosingtheGaps1
See Each Patient at Least Once Each YearThe health status of a Medicare Advantage patient needs to be re‐determined each year. Diagnoses from a prior year do not “carry over” for CMS.
2Evaluate and Document All Chronic ConditionsAll conditions that constitute the “composite health picture” of the senior patient should be evaluated and documented clearly and legibly in the progress note of the medical record.This is not limited to what brought the patient to the doctor today. What other conditions is thepatient dealingwithevery day?
3Code All DiagnosesThe codermust be careful to capture all diagnoses thathavebeenproperly documented. Does the coderhaveaccess to the latest ICD‐9‐CMcodes? Does the coder code to the highest levelof specific toaccurately report the levelofdiseaseseverity?
4
Use an Accurate, Up-to-date Superbill (or Favorites List in EMR)If a superbill is used, does it contain a wide variety of ICD‐9‐CM codes to allow the specificity of the disease to be coded accurately? Is it up to date? Are providers trained towrite in additional diagnoses if they apply or do they use the closest match on the superbill instead? Is the superbill evaluated each year to ensure it meets the needs of thepractice?
5Make Sure the Data is CapturedThe provider must be aware of the limitations of their practice management system. Howmany diagnosis codes does the system allow? Is there potential for any codes to be dropped?Is the provider correctly sequencing the diagnoses?
6
The Claim or Encounter Format or Form Must Contain All the DataWhen the data is extracted for claims or encounter reporting, are all diagnosis codes extracted to be sent to the health plan? Does the claim process limit the number of diagnosesthat can be submitted? Is the practice in the habit of only sending one or two diagnosis codes to support the CPT code on the claim?
7
Verify that Clearinghouse or Submission Vendor Can Send and Receive All Recorded CodesHow many codes can the vendor support for data submission? Are valid codes being dropped because the provider has not updated the number of codes that can be submitted?Many claims systems and practice management systems are being enhanced to capturemore data due to HIPAA data requirements. Has the vendor’s submission been expandedto accept additionaldataaswell?
8Verify that Health Plans Can Send and Receive All Recorded CodesNot all health plans have expanded their systems to accept large numbers of diagnosis codes. Howmany codes can your payer accept? What happens to any codes submitted beyondthe accepted number? Is there an alternative submissionmethod (ASM) available?
• HEDIS
• Contractual Quality Measures
• STARS Program
• Very large domain of quality measures for different entities
• Osteoporosis Management
• Rheumatoid Arthritis
• BMI Assessment
• Asthma Management (potential)
• Depression Screenings (potential)
RiskAdjustmentandClinicalDepartments
Buy,Build,orBoth?
Optimal Performance
In‐house department with some
key elements vended
Majority of functions vended out
All functions done in‐house
TypicalVendorFunctions
Prospective & Retrospective programs
Dash boards and reporting
Chart retrieval
Coding
VendorManagement
RFP/I
• When considering a vendor, a well thought out RFP/I must be developed
• Review the replies carefully
Monitor Deliverables
• Have a clear SOW in the contract and ensure that all portions are being met
• Prepare for systems integration issues.
Problems
• Identify any issues with vendor; determine origin of problem. Did the plan contribute to the issue; if so, how. Work collaboratively as partners
• Develop a CAP (Corrective Action Plan) addressing all contributing factors
CodingQuality– FoundationofRiskAdjustment• Monitor coders on a regular basis and track results
• Use external coders to audit your internal coders
• Spend the extra money and do blind coding
• Use third party coders to monitor vendor coding
• Voldemort
• Develop internal coding guidelines to address grey areas
• Select a random set of records and have internal, vendor, and 3rd party code the same records
• Identify all areas where there are differences• Determine the ‘correct answer’; where there is one
• Carefully review differences that fall into the grey areas
• Decide where your plan falls on the Conservative – Aggressive spectrum• Conservative approach sacrifices some dollars now to avoid penalties later
• Aggressive (not fraudulent) approach accepts more of the grey areas for dollars now
• Working with the audit results, identify and develop guidelines for coding grey areas that fall within your spectrum
HHSRiskAdjustment
Building Blocks of HHS Risk AdjustmentHHS Model HCC Model:
Compare & Contrast
HHS Model Premium
Stabilization: The Marketplace
HHS Model Payment
Integrity: RADV
HHS Model
HCC Model:Compare & Contrast
HHS Risk Adjustment: Same Heritage as CMS Risk Adjustment Model
While conditions and weights vary, the main determinants of risk scores are the same: Age, Gender, Diagnosis codes HCCs
Diagnosis‐based and hierarchical
Same sites of services and provider types
Diagnoses addressed yearly in “face‐to‐face” encounters
Key Differences:
121
CMS (Medicare) ACA (Indiv/Small Group)
Prospective Concurrent65+ Population 0‐64+
Single Model (Part C) 3 Models (Infant, Child, Adult)
All plans can receive payment Plans send or receive payment transfers based on relative risk score to market.
RAPS & EDPS (full encounters) EDGE Server (de‐identified data)
Key Characteristics of Risk Adjustment Models
• Most models are additive:
• Each category (groups of diagnosis codes) is
assigned a weight, which when added together
comprise the risk score for a particular member
CMS‐HCCs (Medicare), HHS‐HCCs (small‐
group/individual) and most Medicaid risk
adjustment models (CDPS, DCGs,
MedicaidRx, etc.) are all additive linear
models
(The Johns Hopkins ACG System, used by several
Medicaid programs, is not additive (tree‐based). CRGs,
used by New York State Medicaid is also a non‐additive
model)
Courtesy of Richard Lieberman
HCC 1 wt. + HCC 2 wt. + HCC wt. 3= Risk
Adjustment Factor
Key Characteristics of Risk Adjustment Models (cont’d.)
• Prospective models use categories derived from prior period data
to predict cost/utilization in a future period and there is a lag
between risk assessment period and payment year
• Concurrent models use categories from a period to explain
cost/utilization in the same period
• Risk scores reset every year [Really? Yes]
• Risk scores are always assigned to individual members, however…
123Courtesy of Richard Lieberman
Key Characteristics of Risk Adjustment Models (cont’d.)
Different product line sponsors designed their methodologies very
differently:
• Medicare Advantage: Assigns risk scores to individual members
and pays for each member individually
• Medicaid: Most states pay at the plan level with a multi-year lag;
others for each member individually
• Health Benefit Exchanges: Will pay at the plan level, with no
payment lag
124Courtesy of Richard Lieberman
Exchange Risk Scores Are Normalized to the State-Wide Average
• Medicare Advantage: risk scores are purely individual, only
related to the entire Medicare population of 49 million beneficiaries
• Health Benefit Exchanges: plan-level risk scores are compared to
other plans in the same state, within metal level
• Medicaid: risk adjustment tends to work like small-group/individual
market risk adjustment, with standardization to a plan-wide average
or typically at sub-state regions
125Courtesy of Richard Lieberman
Risk Score Normalization
Courtesy of Richard Lieberman
Risk Adjustment Model & Methodology(Medicare & Medicaid)
127
Risk Adjustment Administrator (CMS or State
Medicaid)Pharmacy
Data
Medical Claim Data
Eligibility Data
Courtesy of Richard Lieberman
Risk Adjustment Model & Methodology (Exchanges)
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Risk Adjustment
Administrator (Exchange)
Issuers’ Edge Server
Pharmacy Data
Medical Claim Data
Eligibility Data De-identified Risk Assessment
Scores/Prevalence Data
Courtesy of Richard Lieberman
Data Required for Risk Score Calculations
• ICD-9-CM diagnosis codes
• CPT-4/HCPCS
• Bill types
• Acceptable source of data
• Claims
• Encounters
• Paid claims only? “…diagnoses reported on institutional and medical claims that result in final payment action or encounters that result in final accepted status.”
129Courtesy of Richard Lieberman
Diagnosis Overlap Is SignificantStillabout1/3newinHHSmodel;numberingofHHS‐HCCsnotrelatedtoCMS‐HCCs;HCCswithinagrouphavesamecoefficient
HHS vs Old CMS Model HHS vs New CMS Model
130
Three Models – Adult, Child, Infant, each with some unique differences
Makes clinician training and data mining complex:
Antidote is to completely and accurately capture diagnoses
Adult Model (Age 21+)
Child Model (Age 2 – 20)
Infant Model (Age 0‐1)
Applicable model is determined by the age at the end of the benefit year (Exception: Infants born at the end of one benefit year and discharged in the second benefit year are considered age 0 for both years)
131
Adult Model (Age 21+) –someconsistencywithchangestoCMSmodel(Diabetes,CKD),thoughsomerecentlyaddeddiagnosesfromtheMedicaremodeldidn’tmakethecut
What’s new and/or different?
Cancer HCCs expand from 4 in the old CMS model (5 in the new CMS model) to 6 in the HHS model
>650 Pregnancy diagnoses (more than ½ of new diagnosis codes)
Some HCCs age‐dependent
Breast cancer appears in 2 HCCs dependent on the age of the member. (< 50 or 50+)
Pregnancy spans both the adult and child models (ages 12 to 55)
In CMS, not in HHS (examples)
Morbid obesity
Stable Angina
Old MI not in either model
Alcohol dependence
Complications from alcohol dependence are in the model
Cannabis dependence
Other drug dependencies are in the model
Exudative Macular Degeneration
132
In HHS Model Diagnoses Differentphysicianspecialtiesneedtobetrained;alsocongenitaldefectsnottypicallydocumentedandreportedannually
CNS Infections hierarchy
Hydrocephalus
Heart Infection/Inflammation
Acute Pancreatitis and other Pancreatic
Disorders (including celiac disease)
Autism and Pervasive Developmental
Disorders
Transplant status codes have been spread
across the model in multiple HCCs
Anorexia, Bulimia
Personality Disorders (e.g.,
Obsessive‐compulsive disorder,
antisocial personality)
Cleft Lip and Palate
Congenital Disorders (including
heart for infant and child models)
Chromosomal Abnormalities (e.g.
Down’s syndrome)
133
Not All Interactions Are Created Equal: SomeHCCshavesignificantimpactonriskscores.Perhapsobvious:Highseverityillnessesrequireappropriatetreatment,care,etc.
Interaction Types
High Cost Interactions
Medium Cost Interactions
Only one interaction may be assigned to a
beneficiary
If both high and medium interactions are
present, only the high cost interaction will
be applied.
Variables used in determining interaction level
and coefficient
Severe Illness Indicator
Interaction Factor (designated HCCs)
Adults with a severe illness may have high cost
interactions
E.g. Adult with seizure disorder and convulsions
(HCC 120 – is a “severe illness”) and
opportunistic infection (is a high‐cost
interaction), so coefficient would be = 12.427
(silver tier)134
“I’m trying to think, don’t confuse me with facts” – PlatoInfantmodelhasinteractions,butchildmodeldoesnot
Child (Ages 2‐20)
Largely same diagnoses as adult model (82 diagnosis
codes are in child but not in adult model)
Coefficients are different
Age parameters for some HCCs
Pregnancy diagnoses (age 12+)
Other diagnoses e.g. alcoholic cirrhosis of the liver
(age 15+)
Others end at age 17 (e.g. SIDS, Reye’s syndrome)
Infant (Ages 0‐1)
Similar to adult interactions
Only most severe diagnoses count (in conjunction with
maturity/age factor)
Diagnoses/HCCs collapse into severity levels that
include virtually all of the adult and child HCCs
E.g. a full‐term infant with an intestinal transplant,
coefficient = 131.511, extremely immature infant with
same condition = 391.399 (both silver tier)
135
Interactions = No Interactions = Yes
Combining Maturity Level and Severity Level to Calculate HCC Coefficients
Group Infant Silver Metal
Term* Severity Level 5 130.511
Term * Severity Level 4 18.560
Term * Severity Levels 3 5.765
Term * Severity Levels 2 2.925
Term * Severity Levels 1 0.998
Age 1 * Severity Level 5 61.217
Age 1 * Severity Level 4 9.988
Age 1 * Severity Level 3 3.007
Age 1 * Severity Level 2 1.665
Age 1 * Severity Level 1 0.333
Age 0 Male Add‐on 0.574
Age 1 Male Add‐on 0.094
136
HHS Model
HCC Payment Model
Basic Form of the Payment Transfer Calculation
Courtesy of Richard Lieberman
Risk Adjustment at the Plan Level
Plan 1Average risk score
= 0.9Exchange
Plan 2Average risk score = 1.1
Courtesy of Richard Lieberman
HHS Risk Adjustment Payment Transfers Are Simple……onlyifyou’reanactuary,oryoulikemath!
140
• Reported risk score in state market
Plan Level Risk Score
• Weighted average of all health plans in state market
Market Risk Score
•Factors that are function of benefit design / membership
•Age, metal tier
Plan Allowed Rating
•Weighted average of all health plan factors in state market
Market Allowed Rating
•Weighted average of market premiums
State AvgPremium
HHS Risk Adjustment Is a Zero-Sum Game:
141
Health Plan #1 Health Plan #2 Average/Total
Member Months 600,000 360,000 960,000
Average Members 50,000 30,000 80,000
Premium PMPM 310.00$ 300.00$ 306.25$
Risk Score 1.000 0.950 0.981
PMPM Adjustment 5.85$ (9.75)$
Premium Adjustment 3,511,146$ (3,511,146)$ ‐
Net Premium PMPM
(after Adjustment)315.85$ 290.25$
‐ ) * $306.25 = $5.85
Reimbursements to health plans for higher risk occur by transferring funds between health plans within a state (or rating area)
Risk Score Payment Formula Is More Complex
Remember, data on Edge server is de‐identified
142
Reflected in Risk ScoreNot Reflected in Risk Score
Acute Diagnosis Other Diagnosis
Hypothetical Example
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Member Status
HCC Weight 4.215 1.120
Not a member Member in risk adjusted Small Group plan
Risk score does not reflect HCCs captured when patient is not member (unlike CMS model)
Summary of Risk Adjustment Process Timeline
2013
143
March 2013Final HHS Payment
Notice
Throughout 2013Technical Requirements Released/ Operations
Implementation Specifications for Data Storage Issued
2014
January 2014-April 30, 2015
Issuers populate Edge server with
data
2015
April 30, 2015 Reinsurance and Risk Adjustment data collection
deadline
June 30, 2015Payments and
charges for implementation for Benefit year 2014
Courtesy of Richard Lieberman
Same Pattern Repeated in 2016
HealthCare Reform Premium Stabilization Programs: The Three R’s
144
Risk Adjustment is the only permanent feature
Forces insurers to compete based on quality, service, and price ‐ not their ability to draw good risk
Goes hand‐in‐hand with regulations that prevent insurers from denying care to those with pre‐existing conditions
Results in insurers being more equitably compensated for the health burden of the people they insure
Summary of 3 R’s By Market
• 145
Sold withinExchange
Sold Outside Exchange Who Administers
ACA Provision
IndividualSmallGroup
IndividualSmallGroup
Grand-Fathered
State Run Exchange
Federal Run Exchange
Risk Adjustment
Yes Yes Yes Yes NoState or
HHS1HHS
Reinsurance Yes No Yes No No StateState or
HHS1
Risk Corridor Yes Yes No No No HHS HHS
1State can decide to administer or allow HHS to administer. If HHS administers, all parameters will be federal.
Courtesy of Richard Lieberman
Reinsurance Parameters
• Reinsurance available for the first three contract years
• $60,000 attachment point
• 20 percent co-insurance from $60,001 - $250,000 per member
per year
• National reinsurance cap of $250,000
• Issuers can purchase private reinsurance for liability above $250,000
• CMS will charge issuers $5.25 pmpm for reinsurance
146Courtesy of Richard Lieberman
Differences in Timeline Impact to Chart Review and Data Mining Operations
Payment transfers will occur six months after the benefit year
Risk scores based on diagnoses, de‐identified in health plan possession by April
30, 2015 for 2014 Plan year (2014 revenues)
Payment transfers based on differences in risk scores will be invoiced by HHS by
June 30, 2015
Other key difference is that percentages of members with HHS‐HCCs (based on
FFS data) is lower
Adult 19%
Child 9%
Infant 45% 147
Population is different and members have fewer chronic conditions (only 20% of adults based on FFS data) – maybe all hay, no needles!
HHS Model
Data Integrity and RADV Model
Rulemaking, Data “Submission” and RADV:
Markedly different–will keep you on your toes
149
Rulemaking Timelines Differ Between CMS and HHS Models
Benefits & Parameters (proposed rule) published in December (vs. mid‐February for CMS)
Comment period under 30 days (vs 14 days for CMS)
Final notice comes out in March (vs April for CMS)
Data Stored on Edge Server or Amazon Cloud
Unlike MA risk adjustment, data will reside within a health plan’s database (Edge server or Amazon cloud) and will not be “submitted” to HHS
Risk Adjustment Data Validation
All issuers (health plans) required to perform annual Risk Adjustment Data Validation Audits on their data under HHS oversight
RADV results impact future year “premiums”
HHS RADV Will Be Annual 100% for All Plans
CMS
Sample Stratification
Hi, med, low, based on the disease component of the member’s risk score
Auditor
Both initial and second validation conducted by CMS contract auditors
Extrapolation
Yes – Plan year being audited
HHS
Sample Stratification
Hi, med, low per model (adult, child, infant), based on age group, risk level, and presence of HCC
1 stratum for population with no HCC
Initial validation by auditor retained by plan, second level audit by HHS
Yes – Future year
150
Will it be more complex? Extrapolation? YES
HHS RADV: Informational for first two years, but will have “teeth!” – Focus on accuracy as well as completeness
CMS
• Acceptable Visits
• Face‐to‐face encounters
• Eligible “physician” provider
• Risk Score Error Types
• Unsupported HCCs
HHS
• Face‐to‐face and tele‐health (to be defined)
encounters
• Eligible “physician” provider
• Unsupported HCCs
• New HCCs (zero tranche)
• Demographic data errors
151
Maintaining Payment Integrity
• Comprehensive audits are necessary because of the relative nature of the risk scores across all issuers in a state
• Issuers will hire their own, Initial Validation Auditors (IVAs) to conduct the RADV audit
• CMS will audit the IVA auditors using Secondary Validation Auditors (SVAs)
• Financial impacts of audits will not be applied retroactively
152Courtesy of Richard Lieberman
Risk Adjustment Audits in the Small-Group Market
• Audit program to look like Medicare Advantage (RADV)
• BUT, every issuer get audited every year!
• RADV audits are state-specific
• Approximately 300 members will be audited each year per
issuer
• Audit results are extrapolated to all members and applied to a
future year’s revenue
• No financial sanctions for 2014 and 2015 contract years
153Courtesy of Richard Lieberman
Timeline for Implementation for 2014 Plan Year
2015
March 2015 Issuers Provide
Auditor Information to HHS
April – June 2015Selection of Audit Sample, Issuer/Auditor Training, & Distribution of Sample to
Issuers
July – November 2015
Initial Data Validation of Auditor Sample
2016
December 2015-March 2016
HHS Oversight of Data Validation Audit Sample
April – May 2016Announcement of HHS Findings and
Processing of Appeals
June 2016 Estimate Risk Scores and
Stimulate Payment Adjustment
Courtesy of Richard Lieberman
Quality Improvement and Reporting:
FEDERAL GUIDANCE AND RULES: FEDERALLY- FACILITATED EXCHANGE
Certification Year
QHP issuers without existing accreditation
QHP Issuers with existing Commercial, Medicaid accreditation for the state
Year 1 (2013) Schedule accreditation reviewAttest that accredited policies and procedures are comparable to Exchange (not all the same)
Years 2 and 3 (2014-2015)
Be accredited for Exchange product(policies and procedures)
Attest that accredited policies and procedures comparable to Exchange
Year 4 (2016) Exchange product is accredited data, performance data submitted
Courtesy of Richard Lieberman
Some Key Take-Aways
1. Risk score and payment calculation (more complex) is zero sum game – dependent
on metal mix of membership, market risk – there will be “winners” and “losers”
2. Members have fewer chronic conditions (only 20% of adults based on FFS data) ‐
need to be data ninjas. Also, clinical onboarding (required for Covered California) to
identify conditions early becomes increasingly important
3. Differences in timeline – concurrent model and 4 months after data year for HHS,
13‐25 months for CMS – Implications to chart review and data mining operations –
need to bring members in sooner, fully document and code conditions at first visit
156
Some Key Take-Aways
4. Diagnoses overlap, some diagnoses in HHS, not in CMS Different physician
specialties need to be trained (Pediatricians, Ob‐Gyns, etc.), place additional focus on
high impact HCCs (transplants, ESRD, hemophilia).
5. RADV for every plan, every year (informational in first two years, then it really
matters). This RADV has teeth. Initial validation audit, secondary validation audit.
Potential for other errors. Focus on accuracy as well as completeness.
157
WRAPUP
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