Risk Adjustment Data Validation (RADV) Audits Just Got Real
Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company's risk adjustment coding and data collection practices. The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act. The company has over 3.2 million Medicare Advantage members.
For years CMS has struggled to define the process and methodology it would use to pursue payment recoveries from Medicare Advantage plans which were overpaid under risk adjustment. In 2012 it finalized its process and launched its first round of RADV audits, on a parallel track with those being conducted by the Office of Inspector General at the Department of Health and Human Services.
The Justice Department's involvement in the Humana audit would appear to indicate the review is in the advanced stages and has been underway for some time. The methodology assures an extrapolated repayment to the Federal government for unsubstantiated codes submitted for risk adjustment. That this action also comes in connection with the False Claims Act and a qui tam whistleblower action could signal serious trouble for the insurance giant.
RADV just got real.
Resources
GHG can support your risk adjustment from start to finish when it comes to preparing for your RADV audit and prepare a readiness plan. We're standing by to support you in comprehensive audit coordination, limited audit oversight and targeted engagement services. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
CMS Releases the 2015 Audit Protocol: Critical Next Steps to Avoid Becoming A Casualty of Reasonable Expectations
On February 12th, CMS released the 2015 Audit Protocol. The question on everyone's mind is — what does this mean for 2015? Well, it means a few things. Outlined below are some of the most impactful changes, as well as the "why" behind the change, and the trends that continue to emerge.
1. CMS has initiated a new audit cycle — this means that even if your Organization was audited in 2012, 2013, OR 2014, your Organization could be audited again this year.
2. CMS has included language with fangs around universe submission accuracy. For any Organization that has been audited in the last few years, this will come as no surprise. CMS has narrowed in on the fact that Organizations have a disturbingly hard time pulling accurate universes. The fact is that a dirty universe is a symptom of a much larger issue within the Organization — and CMS knows it. With the 2015 audit cycle, CMS will allow a maximum of three (3) attempts to submit an accurate universe. After the second failed attempt, CMS will automatically document an observation, and after the third failed attempt, the Organization will be cited an Immediate Corrective Action Required (ICAR) — for EACH condition that cannot be tested due to inaccurate universes.
3. CMS will again measure timeliness at the universe level for standard and expedited organization determinations, appeals, and grievances (ODAG) and for standard and expedited coverage determinations, appeals, and grievances (CDAG). However, in 2015, while CMS will request the same data as in past years, now each separate request will have its own universe template. What's the relevance here? This means that any programing that your Organization completed around current universe requests must be redone. This may seem like a small thing, but with the increased focus on review at the universe level, the increased emphasis on universe accuracy, AND the historical difficulty the industry has had with pulling accurate universes — this should be top on your Organization's list.
4. CMS has modified long-standing audit protocols such as the Compliance Program Effectiveness protocols which were "redesigned to be more outcomes focused and less burdensome". CMS will now test all seven elements of Compliance by pulling tracer samples, which means that CMS will trace the sample through the Organization to determine compliance. The move to using the tracer sample review for all seven elements is very telling. We see here that CMS is continuing to move toward a method of results oriented review vs. a review based on Organization policy. In other words, if you can't demonstrate Compliance, it probably doesn't exist.
5. CMS will incorporate two pilot review areas in 2015. First, review of the Medication Therapy Management (MTM) Program, which is to be expected with CMS' continued focus on Part D. Second, and more interesting, is the addition of the Provider Network Adequacy pilot. At first, you may wonder why CMS decided to include this out of all possible additions. Well, the answer is that CMS has become aware of issues with access to care, and these issues extend to access to physicians. In other words, your Organization must ensure that it is meeting network adequacy standards, specifically for specialty and sub-specialty providers, AND that the providers are open to treat enrollees.
As we can see from the above, CMS administrators are true to their word — CMS continues to intensify its focus on the health and well-being of the beneficiary, and they should. As John Gorman and I discussed during our webinar held on February 13th, titled, "Top 10 Things Killing Your MA Plan," CMS continues to have a laser focus on those issues that have potential to cause imminent beneficiary harm and weeding out those Organizations that are not able to appropriately care for the Medicare population — a trend which is clear both by the continued refinement of the Audit Protocols and by a steep increase in CMS Civil Monetary Penalties and Sanction Activity.
Don't know where to start? Contact us today and a team member will be in touch with you shortly.
Resources
In the Common Conditions, Improvement Strategies, and Best Practices memo based on 2013 program audit results, CMS outlined areas where plans have been consistently non-compliant and described best practices to address failings. Ongoing monitoring is at the heart of non-compliance. Our solution, the Online Monitoring Tool (OMT™), streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Countdown to Final Submit
Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way.
- CMS has not updated their Part D readme file to include the FDR chart noted in 3.1.1C. It seems a bit redundant to the information entered in the Part D Data section of HPMS, but to each his or her own. CMS provides no template for that chart so we can imagine either it is overlooked upon initial submission by the applicant, or it is submitted in varied forms.
- Despite making reference to an additional webinar to be held after the second user call, no webinar was scheduled nor was any announcement made to correct that statement. However, CMS staff demonstrated timely responsiveness to posed questions both directly sent to application contacts as well as through the DMAO mailbox.
- With an industry push for quality (read: limited) network establishment, applicants can expect a high level of scrutiny on exception requests. If providers are available in a service area, CMS has stated that applicants should not even submit an exception request, so put those pencils down and step up contracting efforts.
You have until 8:00 PM Eastern Time tonight to submit your application. There should be a good sense of what potential deficiencies exist, so maintain the momentum to fill those gaps. Embrace the reality that CMS may certainly identify additional gaps in the submission. Ensure that your team has time built into your implementation plan to address any additional deficiencies.
Resources
We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Contact us today to ensure a smooth, compliant process.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
In 2015 a Slap on the Wrist Can Be the Kiss of Death
It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government. 2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS). It's already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans. And generally speaking, the regulatory bar is rising faster than anyone imagined. Consider:
- So far in 2015 CMS has issued significant new Medicare Advantage and Part D regulations, and this year's Advance Notice for 2016 rates and rules for Medicare and Part D health plans is the most anticipated I can remember in more than 20 years.
- 2015 is the toughest year in benchmark payment rates thanks to the approximately $200 billion in cuts from the Affordable Care Act.
- 2015's technical corrections for Star Ratings are almost bewildering in their complexity in raising the clinical bar. Indeed, in 2014, an election year, CMS famously told Medicare Advantage plans below 3 Stars for 3 consecutive years that a stay of execution was granted. In the fall, many of those low performers were quietly shown the door and were non-renewed. In 2015, however, the agency is handing out live ammunition to its firing squad. Now an intermediate sanction freezing marketing and enrollment automatically knocks the plan down to 2.5 Stars, often meaning loss of millions in bonus payments and rebate dollars. In competitive markets now, the first plan sanctioned is the first hunk of roadkill.
- The HHS Office of Inspector General, the guys with the badges and guns in Medicare, have made data validation audits for Medicare Advantage risk adjustment one of its top priorities in its 2015 workplan. And the President's budget includes over a half-billion dollars in recoveries from these RADV audits.
- But nowhere is there better evidence that the paper tiger is growing its claws back than in CMS' track record in enforcement actions against MA plans. In January, the agency levied the highest monthly toll of civil monetary penalties ever -- and if it keeps up the pace, 2015 will be nastiest enforcement environment in Medicare history.
*January 2015
Granted, CMPs don't typically amount to much, usually no more than a couple hundred grand, rarely 7 figures plus. But the damage is actually far greater, when considering damage in the local and national press; the chatter factor among beneficiaries; lost membership, and damage to the Star Rating and the relationship with CMS, which for many plans is or is becoming its biggest customer. A slap on the wrist is now the kiss of death in this environment.
Last week, my colleague conducted a webinar on the "Top 10 Things Killing Your MA Plan." CMS' top infractions, in order, are coverage determinations and grievances, and formulary administration, or performance of your pharmacy benefits management vendor. Those findings are driven by these 10 root causes:
Now is the time to ensure your compliance function and Medicare operations have the right tools, processes and people to be successful in the toughest environment we've ever seen in government health programs. In 2015, Gorman Health Group launched its latest product, CaseIQ™ , providing a new way to ensure your Appeals & Grievance cases come to a timely and compliant resolution. The tool not only captures all the data points needed to categorize, work and report coverage disputes and complaints; it also guides users through the appropriate processing of each case, minimizing the risk of non-compliance due to user error. Built and governed by GHG Medicare compliance subject matter experts, CaseIQ™ aims to keep our clients out of CMS' audit crosshairs. Learn more in our recent press release.
In addition, in the Common Conditions, Improvement Strategies, and Best Practices memo based on 2013 program audit results, CMS outlined areas where plans have been consistently non-compliant and described best practices to address failings. Ongoing monitoring is at the heart of non-compliance. Our solution, the Online Monitoring Tool(OMT™), is a highly flexible oversight tool and dash boarding software that brings together key metrics, documents, and tasks for ongoing monitoring and auditing, which results in the Organization being audit ready. This integrated solution also streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.
Resources
CaseIQ™, GHG's latest solution, offers built-in reports that allow for tracking of past performance, current backlog as well as trends, and is designed to assist the caseworker to a complete and compliant resolution in Part C (MA) appeals, Part D appeals, and Part C and Part D grievances. Learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
2016 CMS Applications: Highlights and Basics
This week's CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear. The recording is already available to registrants for those who missed it. There was way too much information for me to summarize, so I have included here a few highlights from the call and some basics that are easily overlooked.
Highlights
All new Part D applicants (MA-PD and PDP) who do not have a Part D contract with CMS that has been in effect for one year prior to application submission, must use a contracted first tier, downstream, or related entity (FDR) that has one year experience in the last two years performing functions in support of another Part D contract. Also, new PDP applicants must have two continuous years' experience offering health insurance immediately prior to submitting the application or five continuous years actively managing prescription drug benefits. CMS confirmed that the applicant can use the experience of a parent or subsidiary of its parent to comply with these requirements.
CMS also highlighted that applicants must validate their home infusion (HI) and long term care (LTC) pharmacies prior to submission. They must have valid NPIs. If you upload invalid information, the application will be considered deficient. This reminder is certainly a result of last year's CMS exercise of calling HI pharmacies directly to ask them about the services they perform. Based on the tone of yesterday's call, there is low tolerance for applicants that do not verify this information. They further mentioned that applicants must make sure their ITU file matches ITU reference file. "Even if the spelling is wrong, please use the wrong spelling." You will need to listen to the entire call recording to catch all the information provided, but the slides are a good start.
Nail down the basics.
- It may seem trivial, but make sure you have the right contact name in the Part C Application Contact and Part D Application contact fields. Earlier last year when CMS sent their first round of deficiency notices, only the application contacts received the emails at the plan — no one else. With only one week to address deficiencies or gaps after that first notice is received, it is imperative that the right contact is in place and that they are aware that they need to monitor notices from CMS quite closely.
- Cross-walk documents using pdf page numbers. CMS has quite a bit of information to review so point them directly to the requirement in your document, be it the Quality Improvement Plan or the PBM contract.
- CMS stresses to follow instructions and use the new templates for the Part D application; do not use anything from previous years. Also, do not submit such a thin application that is indicative that it is simply a placeholder for more time.
Make sure your effective dates are in line with the application requirements.
· Consider your licensure and contract effective and end dates. For example, your state license or certificate of authority needs to be in effect to cover the entire 2016 plan year. If yours expires mid-year, you can expect a deficiency unless you upload documentation showing the certificate covers the entire plan year, or other documentation such as proof of payment for the renewal.
· If you have a subcontract of an FDR that you must upload to CMS based on the fact they are performing a key Part D function, ensure that the effective date is appropriate. For example, one key Part D function is enrollment processing. Enrollment functions must be in place and operational during the AEP. Therefore, ensure that the effective date of a contract is in line with the time frame for which they will begin working with Part D beneficiaries on your behalf. (Remember: if delegating this or other key Part D functions to a parent organization, that executed subcontract must be uploaded. As mentioned in last week's call, the Part C agreements are not required this year for upload. )
In a couple days, I'll post some interesting things that our team has encountered along the way that may help shed light on the application documentation. For example: is there an upload missing from the Part D readme file? There sure is. Is there something in the PDF application that doesn't quite match HPMS? A couple things, actually. If you have questions, by all means follow CMS' instructions for questions! However, if you find anything that doesn't quite make sense that you'd like to share, we'd love to hear from you.
Resources
The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow up questions. Visit our website to learn how GHG can help >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
2016 CMS Application Season Begins
Yesterday CMS released the 2016 Part D application, and this afternoon the 2016 Medicare Advantage (MA) application was released. Despite the applications' release dates, potential and current Plan Sponsors should be well under way in the preparation of the upload that is due on February 18th. Aspects of the application that require significant lead time to accomplish include the establishment of an adequate network and the acquisition of the required state licensure.
If you haven't done so already, register for the industry user calls; these are scheduled to be recorded and available on the MSCG website a few days after each call. Today's industry training was delivered by CMS' Arianne Spaccarelli, Paul Foster, Nisha Sherry, Melissa Cooley and Greg Buglio. They provided an incredible amount of detail regarding the Part C application process, Special Needs Plans (SNP) proposals, and automated application training. It is worth listening to the recording, but here are some highlights:
Past performance will be considered — 14 month look-back. This was provided as a reminder in the past but this is in the regulation. See 422.502(b)(1-2) for the detail; boiled down, if during the past 14 months the MA organization fails to comply with the requirements of the Part C program under any current or prior contract, or in absence of 14 months of performance history, CMS may deny the application. You might be wondering if this is also outlined in the Part D regulations. It certainly is; in 423.503(b)(1-2) CMS also outlines the same for Part D organizations.
A major change that appeared in the draft 2016 MA application and made it to the final version was the deletion of the upload requirements for provider contract templates, executed administrative contracts/LOAs, and their respective crosswalks to regulations. This change reduces the burden to applicants in the short term. CMS stressed that attestations are still required to comply with these requirements and CMS may request that documentation at any time. (From our perspective, it is highly recommended that applicants consider incorporating the CMS-developed model contract amendment for MA administrative and management contracts, and for first tier or downstream entity provider contracts. You can find that on the MA applications site. Plans who do not use the model amendment may find themselves missing the spirit of the requirement if they do not include the exact required language. Worst case scenario? CMS comes a-calling, and picks apart your contracts. Why risk it? )
As in past years, there is an order to completing the steps of the application, and those steps have been outlined in the training. A number of inexcusable reasons for requesting an extension were described in delightful detail. They include trying to upload your provider and facility tables at the last minute, forgetting to hit the Final Submit button, or simply being unaware of your service area needs for your application. Listen to the call — they just aren't having it!
Keep track of the GHG blog where I will provide some additional lessons learned from past applications, quirky issues that applicants often face, as well as important things to remember. Don't go it alone if you can help it; many hands make light work with this type of project.
Resources
The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization.Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
ICD-10 Transition — Ready or Not?
It's a New Year and there are 262 days left until the October 1, ICD-10 implementation deadline. The road to ten has been very challenging with respect to "Go or No-go" implementation timelines. Due to several delays, many organizations literally stopped transition efforts and redirected funding budgets to other priority projects.
The big day is coming! Currently, it is a known fact that CMS is operating under the October 1, 2015 scheduled deadline. It is now crunch time and with the compliance deadline set organizations have minimal time to complete the transition. Thoughtful planning, and executing conversion plans, will overall make the difference between a successful transition and missing the deadline.
What happens if your organization is not fully ready?
What is your plan for remediation?
The transition does not have to be painful. Timing is everything. Health plans and organizations, such as providers, clearinghouses and vendors can still benefit by using the time left to focus and implement additional readiness and deployment strategies for the code switchover.
The International Classification of Diseases, Tenth Revision (ICD-10), consists of two new areas, clinical modification (ICD-10 CM) for diseases and procedural coding system (ICD-10 PCS) and will replace ICD-9. The switch in code sets will provide expanded detail for inpatient, ambulatory and managed care organizations to better define medical conditions. The conversion is a significant change to the standard healthcare coding systems.
So what exactly are the differences between ICD-10 and ICD-9?
- ICD-9 codes have three to five numeric digits, while ICD-10 has three to seven alphanumeric digits - the switch in 2012 to HIPAA 5010 transaction standards for electronic claims paved the way for practices and payers to be able to accommodate ICD-10 changes
- CMS will transition all diagnosis codes from 13,000 old codes to approximately 68,000 codes included in the ICD-10 version
- ICD-10 has more specificity with a lot more codes, which provide more detail and granularity than the old codes
- Diagnosis Procedure Codes Systems (PCS) will increase from 3,000 ICD-9 to 87,000 ICD-10 PCS
Based on these changes, transition to ICD-10 requires extensive detailed planning, and comprehensive readiness efforts organizational-wide. It's virtually more than just a coding function. Diagnosis codes affect almost every core functional and operational process, system and reporting. Failure to prepare for the conversion will have dramatic impacts on financials and ultimately the member experience.
By leveraging in-depth regulatory interpretation and guidance with complete operational knowledge base Gorman Health Group provides ICD-10 best practices through financial analysis and impact assessment, which includes people, process and technology. Gorman Health Group will identify gaps between current operational "as is" process flows and recommend future optimal "to be" process flows required for the implementation. The analysis will highlight the impact on margins by line of business and measured through people, process and technology. Additionally, risks and potential return on investments (ROI) for the identified gaps can be provided.
Gorman Health Group ensures end-to-end operational process re-design including but not limited to the following functions:
- Claims
- Benefits & Product
- Configuration
- Codification and mapping
- Contracting
- Division of Financial Responsibility (DOFR)
- Prior Authorization
- Provider Pricing
- Quality Control
- Revenue Cycle
- Reporting and Analytics
- Metrics
- Vendor Alignment
- Vendor Management and Oversight
- All Other Hand-offs "Operational" Areas
If you are behind the eight ball and not exactly on track let us proactively work with you on an expedited readiness plan, contingency plan development, post-production support, post-transition analysis, knowledge transfer, monitoring and reporting. Gorman Health Group includes some of our industry's most experienced and proficient ICD-10 and operational subject matter experts.
Make your New Year's resolution to stay on track with transitioning to ICD-10. Time is running out and October will be here before you know it.
Resources
At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Annual Compliance Program Audit: Your Organization's Achilles Heel?
When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is audited annually. Fulfilling the requirement to annually audit the Compliance Program can present an issue for some Organizations due to the fact that Compliance Department self-auditing does not fulfill the requirement, and there may be no other department within the Organization with the expertise to conduct the review.
Here are a few ideas that we've seen Organizations use in order to fulfill the CMS requirement:
- Hire an external auditing firm.
- Cross-train another department within the Organization to conduct the annual audit.
- Compliance departments of two different Organizations audit each other. Of course, this option may be a bit tricky depending on the competitive landscape. However, it can be a good option if there is no budget to hire an external firm and if no conflict exists (e.g. competing service areas).
An effective Compliance Program is critical to your compliance and operational success. In addition, a strong Compliance Program can safeguard against many compliance issues recently cited by CMS as the cause for civil monetary penalties (CMPs) and enrollment sanctions. Please contact us for more information about the GHG Compliance Program Effectiveness Audit.
Resources
GHG offers guidance and support in every strategic and operational area to ensure alignment with CMS. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are immediately identified. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Rewards and Incentives: Are We There Yet?
Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.
On December 4, 2014, CMS released an HPMS memo titled "Rewards and Incentives Program Guidance" which provides additional guidance related to how Organizations must implement Rewards and Incentives Programs, which, as of July 22, 2014, CMS allows for Part C benefits.
Although the implementation of Rewards and Incentives is no easy task, I think the more pertinent question is how could this new guidance impact your Organization and our industry as a whole? Well, some of that, I think, will remain to be seen as these programs are implemented. However, I do think there are a few challenges and strategies that we should consider as we're implementing these programs - here are a few things to mull over as you're ringing in the New Year:
• What is the competitive landscape for Rewards and Incentives, and how will your Organization ensure that it is competitive while still remaining compliant?
• How will your Organization ensure that your Rewards and Incentives program will have an impact on enrollee behavior?
• How will your Organization track information regarding Rewards and Incentives?
• Last but not least, how will your Organization oversee the implementation of your Rewards and Incentives program to ensure compliance?
So, what is the trend? The fact that Medicare Advantage Organizations are now allowed to provide Rewards and Incentives (for Part C benefits) further indicates that CMS' main focus and main objective is the health of the Medicare population — as it should be, of course. However, we in the industry should take note - along with CMS' continued scrutiny via their program audits (and other mechanisms) of those areas that have the potential to cause beneficiary harm, they are also loosening the reigns in certain key areas such as Rewards and Incentives. The objective here is to ensure that Medicare beneficiaries have access to high-quality health care including any incentives that could in fact have a meaningful change in the way that beneficiaries approach their health care.
For more information or support, contact us today and a team member will be in touch with you shortly.
Resources
Become a member of the Point to receive access to the analysis of all HPMS memos by GHG experts. Already a member? Access the HPMS memo mentioned in this article here >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Medicare and Exchange Risk Adjustment: Data Quality Matters
Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).
With CMS processing the results of the first Medicare RADV audit subject to extrapolation and with the inaugural audits for the Exchanges kicking off in just a few months, plans need to have a blueprint of how they are going to minimize their audit exposure through data analytics. Because of the different demographics of the Exchange population vs. the Medicare population, health plans in the Exchanges have a learning curve to overcome to address some of the more common coding issues associated with diagnoses for this younger population. The HHS-HCC model is more complex than Medicare and has 15 different payment models based on 5 metal levels and 3 different age bands: the adult model (ages 21+), the child model (ages 2-20) and the infant model (ages 0-1). Pregnancy, newborn and congenital coding rules need special focus in order to receive the appropriate reimbursement. Plans need to be proactive in their approach to data integrity in order to remain competitive and minimize government take-backs.
Whether you rely on multiple vendors, an internal team, or a combination of the two, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping stride with CMS and HHS expectations in both compliance and health care outcomes. Our services include:
- Risk Adjustment Strategies — Retrospective, Prospective and Concurrent Outreach strategies, evaluation of staffing structure and levels
- Quality Assurance Programs — Proactive programs to improve data accuracy
- Data Analytics — Identifying data gaps and appropriate gap closures
- End to End Process Review — Testing for dropped data and recommendations for best practices in data processing
- Provider and Coder Education/Coding - including ICD 10
- Risk Mitigation - Identifying unsubstantiated diagnosis codes
- Data Validation — Mock Audits
- Vendor Audits — Coding accuracy, data completeness
- Requests for Proposals (RFP) - Developing RFPs and/or the evaluation of RFP vendor responses
Resources
GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit out website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Don't miss GHG Founder & Executive Chairman, John Gorman, at the ICE 2014 Annual Conference, delivering the keynote address titled "Evolve or Die: A Darwinian Moment in Government-Sponsored Health Programs. To find out what other events GHG experts will be speaking at, visit our website >>