Your Risk Adjustment Road Map
Where are you going? And how quickly are you getting there?
The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors.
Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model. Your transformation should look like this if you have PFFS, PPO, or HMO products:
• Early Model: 1.7 charts reviewed per member with no member evaluations
• Next Model: 0.65 charts reviewed per member with 5-15% member evaluations targeting
• Goal Model: 0.30 charts reviewed per member with 60-85% member evaluations targeting
• SNP Goal Model: 0.50 charts reviewed per member with 100% member evaluation targeting (we will blog more about SNPs soon, due to their unique nature)
This not only offers you more timely and accurate revenue but, more importantly, member information for a comprehensive plan of treatment which should reduce gaps in care and highlight care management needs for the patient population.
If you have questions or need to remodel your strategic plan or budget, we have a client roadmap module to transition your risk adjustment program without impacting accurate revenue or blowing your budget.
A Risk Adjustment Road Map
Where are you going? And how quickly are you getting there?
The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors. Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model. Your transformation should look like this if you have PFFS, PPO, or HMO products:
• Early Model: 1.7 charts reviewed per member with no member evaluations
• Next Model: 0.65 charts reviewed per member with 5-15% member evaluations targeting
• Goal Model: 0.30 charts reviewed per member with 60-85% member evaluations targeting
• SNP Goal Model: 0.50 charts reviewed per member with 100% member evaluation targeting (we will blog more about SNPs soon, due to their unique nature)
This not only offers you accurate, more timely revenue but, more importantly, member information for a comprehensive plan of treatment which should reduce gaps in care and highlight care management needs for the patient population.
If you have questions or need to remodel your strategic plan or budget, we have a client roadmap module to transition your risk adjustment program without impacting accurate revenue or blowing your budget.
If I want a Risk Adjustment Super Hero ....
Ask yourself: What would my 2012 member assessment strategy & timing look like if I want a Risk Adjustment Super Hero?
- Step 1: Compile data in February
- Step 2: Launch member evaluations in March
- Step 3: Complete 50% of your member evaluations by June 30th
- Step 4: Reduce dependence on chart review to .30 charts per member and increase member evaluations to 85% of the membership (for PFFS, PPO, and HMO plans)
- Step 5: Refine analytics and reduce zero HCC member evaluation percentage (should always be less than 30% but you want to push toward 15% if you are not reviewing your entire population)
- Step 6: Check year over year revenue increase Jan — June and July —December for member evaluations to ensure ROI and payment reconciliation
Risk Adjustment: Are you driving a Pacer or an Audi R8?
How can you tell if your risk adjustment program is a high performance machine?
Here is the quick test:
1. Did you hit your volume target for member evaluations for 2011?
2. Did you hit your revenue target for chart review and member evaluations for 2011?
3. Are you planning for a 2012 Quarter 1 launch for member evaluations?
4. Do you have best in class analytics with a constant 5 to 1 ROI or higher for member evaluations?
5. Are you reducing your dependence on chart review?
6. Are you scrubbing your claims based HCCs for validation & confidence levels?
7. What is your percentage of zero HCCs found in your member evaluation program?
8. What is your percentage of zero HCCs found in charts?
9. Do two different coders agree on your findings?
10. Are any of your vendors on corrective action plans with you?
We have a few more questions for you. If you want to morph your program into a high performance machine, now is the time for best practices discussion, strategic planning, and program improvement.
The Secret Sauce of Risk Adjustment: Implementation, Implementation, Implementation
As we are coming close to year end, we have all learned a great deal. The number one thing we hear from health plans: "I thought they could implement."
Risk adjustment is successful only if you couple speed with quality. The three most constant stumbling points for member evaluations programs are
1) compilation of data
2) suspect list generation
3) provider recruitment
As you talk with your health plan and medical group peers, their references and experience should help you navigate this treacherous path.
The questions you may need to ask:
1. How long does it take you to compile and refresh data? Best in class answer: 10 days to compile a health plan or medical group's data and 1-2 days to refresh it monthly.
2. How long should it take to generate a member suspect list? Best in class answer: 5-10 business days
3. How long does it take you to recruit or train or allocate member evaluation providers? Best in class answer: Within 20 days of contract execution, your assessment vendor needs to have their evaluators recruited, trained, and in the field with your members.
Make sure you ask the right questions and pick the right partners. If you selected a turtle this year, you better start looking for a rabbit for 2012. Slow and stumbling does not win the race and you have to win the risk adjustment race to stay alive.
Forbes Gets it Wrong on Medicare Advantage
Forbes recently published a blog post ("Seniors: No, You Cannot Keep Your Plan Even if You Like It") that was wildly off the mark on the future of Medicare Advantage. I commented directly there (my handle on the Forbes blog is MedicareNinja), but had to call it out here.
I agree, the President overpromised to seniors when he famously said during the health reform debate "If you like your health care plan, you can keep your health care plan." You can't cut $135 Billion from plan payments and expect to have no impact on beneficiaries. But Forbes got it wrong: we are NOT about to see another exodus from the program as we did in the late 1990s.
As we've said here before, the exhortations of the death of MA are premature. We got confirmation from CMS last month: MA premiums will fall another 4% in 2012, and enrollment will grow by a brisk 10%. This after a robust 2011 where we think AEP will close with MA enrollment up over 8% vs. 2010.
The plans aren't going anywhere for several reasons -- none of which you see if all you're reading is wonky CBO and MedPAC reports.
First, government programs (Medicare and Medicaid in particular) are the only segments of the insured that are growing. As noted earlier, MA enrollment will grow over 8% this year, topping 12.5 million beneficiaries. Part D is approaching 20 million enrollees. Just this week Cigna announced it's spending over $3 Billion to acquire HealthSpring, a pure-play MA plan. Why? Because they see tremendous continued growth in the program, not because of its imminent demise.
Second, publicly-traded companies like MA leaders Humana and United are now dependent on Medicare, deriving twice their earnings from the program than they did a decade ago (average publicly-traded health plan earnings from Medicare in 1999: 13%; today, 26%, with some like HealthSpring and Universal American over 70%.) Bottom line: the big boys ain't going anywhere.
Third, over 40% of beneficiaries aging into Medicare have enrolled in MA plans the last two years, indicating the Boomers are a much more plan-friendly population than the World War II generation given managed care trends in the commercial market (HMOs, PPOs and POS plans represent more than 90% of all insured Americans).
Fourth, and most importantly, market-leading plans are adapting to the health reform cuts by focusing on Star Ratings quality bonuses and mastering the new state of the art in risk adjustment: the prospective home advanced evaluation. It's working, enabling plans to hold the line on benefits and premiums, and maintaining the attractiveness of these products vs. Medigap or traditional Medicare.
As long as the Congressional deficit Super-Committee doesn't fire another broadside at MA plan payment rates this fall, 2012 is shaping up to be a VERY good year, and I'd venture an estimate of over 15 million beneficiaries in these MA plans by the end of 2015.
The Forbes piece struck me as a wonky political hatchet job, trying to score cheap political points against Obama without any real basis in reality. They're usually above that sort of thing.
New ACO Reg has some zingers
The newly minted ACO regulation from Medicare has some zingers hidden in its 696 pages. Okay, to be fair, the actual regulation is only 70 pages long, double spaced. The rest is all preamble, where CMS describes the 1200 comments on the proposed rule, and how they have responded (or not) in the final rule.
The first zinger has to do with the Physician Quality Reporting System, known to its friends as PQRS. Since 2007, CMS has paid a bonus to physicians who report quality data. Under current rules, CMS will pay physicians ½% of allowed charges from 2012 through 2014. BUT, docs in an ACO will only be able to participate in the PQRS through the ACO. The ACO will report as if it were a group practice. If the ACO fails to report in compliance with the PQRS rules, its docs won't get the PQRS bonus. This could be an issue in recruiting doctors who may not see a clear advantage to the ACO to begin with, given all the other requirements.
A second zinger is the approach to risk adjustment. CMS has agreed to use the Medicare Advantage HCC risk adjuster for newly assigned beneficiaries. They won't use HCCs for continuing beneficiaries — people who were assigned to the ACO last year. HCCs are based on diagnosis codes on last year's claims. CMS reasons that an ACO would improve coding accuracy in year one, to get the best risk adjustment they could for continuing beneficiaries in year 2. So only new-to-the-ACO beneficiaries will get risk adjusted for higher HCC scores. BUT, if the average HCC score for continuing beneficiaries goes down in year two, then CMS will risk adjust and reduce the benchmark accordingly. The inference is that reduced scores could only reflect reduced average risk. So ACOs that are not diligent in keeping their risk scores up could be docked a chunk of money for apparent losses resulting from poor coding, not from poor care management.
To read GHG's summary on the CMS Final Rule for the Medicare Shared Savings Program, click here.
OnStar for Risk Adjustment: Are you Okay?
Did you just hit something — a bump in the road or another car? Is there a calm voice coming from your car, asking if you are okay?
If only there were OnStar for risk adjustment. It is almost year end and if there were an OnStar for risk adjustment this is what she would be asking you today:
• Do you have at least 75% of your chart review done?
• Is your coding accuracy over 85%?
• Do you have at least 70% of your member evaluations completed?
• Have you scrubbed your claims based HCCs for validity or code confidence?
• Have you checked the health plan RAPs filtering process, not just for duplicate, but for complete compilation? Put another way - have you reconciled all the codes from your claims, chart review, and evaluations in the RAPS submission?
• Do you have a strong reconciliation process to ensure accurate payment when you get your RAPS return?
• Do you have an EDPS plan in place?
• Are you moving from retrospective chart review to current year chart review for 2012?
• Are you reducing your chart review strategy for 2012 and replacing it with member evaluations?
• Have you combined your member evaluations with your wellness exam criteria?
• Are you improving member outcomes and your HEDIS & STARS score with your integration of risk adjustment findings?
• Are you tracking the closing of your members' gaps in care?
If you need some roadside risk adjustment assistance, now is the time to ask.
"Lean and Clean" is Key to Survival for Medicare Plans -- Join the exclusive GHG Compliance Forum November 2-4 in Las Vegas
New regs every other week. 500 HPMS notices a year. RADV audits and Star Ratings surveys. Intermediate sanctions and the threat of termination for poor Stars performance. And now a new, uncoordinated CMS Central Office/Regional Office audit approach that could result in multiple government reviews in a calendar year. "Lean and clean" must define a cultural and management revolution among Medicare plans. If you aren't on the compliance train in these next several years, you're going to be under it.
Tell your compliance staff about our latest Gorman Health Group Compliance Forum. This exclusive GHG event is designed for Medicare Advantage health plans and will provide an intensive examination of the state of compliance in MA, with focus on the changing regulatory environment surrounding both Parts C and D. The meeting is limited to GHG client health plan staff ONLY. No vendors, no CMS representatives, to ensure a frank and open discussion about the way forward.
You'll want your team to be in the room to hear the latest from GHG's compliance experts on:
- Practical tips for implementing a fully-integrated compliance program
- Best practice Sales Oversight strategies that have cross-functional impact
- Part D pitfalls and action steps for oversight and monitoring
- Lessons learned from risk areas in compliance, including sales/marketing, enrollment reconciliation and risk adjustment
For registration information and more details, click here.
To check out the preliminary event agenda, click here.
Have a question? You can always reach our team at ghg@ghgadvisors.com.
I'll look forward to seeing you and your team in Las Vegas.
GHG Revenue Management Forum in Vegas Coming October 6-7
We've been saying since passage of the ACA that the next 3 years' survival in Medicare Advantage is all about revenue management. The rules have changed and MA plans need new processes and new solutions to avoid serious financial troubles these next several years. Clinical initiatives often take years to bear fruit. As rates come down due to the ACA cuts, and more pile on from the Congressional Super-Committee, MA plans must pull every revenue lever they have to offset those losses, stay competitive -- and finance the care coordination and complex case management infrastructure essential to securing our long-term future in government programs.
Our clients said, "how?" We're saying: "come to 'Lost Wages' and we'll show you." The venue couldn't be more appropriate for the subject matter. So please join me and GHG's top experts on revenue management October 6-7 at the fabulous Aria Hotel, for an exclusive event for MA health plan senior leadership with responsibilities for finance, revenue management, Star Ratings, and risk adjustment. We will share our state-of-the-art practical strategies for driving revenue in the new age of austerity and accountability.
This forum will offer actionable, tactical insight regarding:
• Performance optimization and efficiency
• Must-have investments in your STARS programs and where to focus to boost your rating
• A cutting-edge risk adjustment program that drives higher, more compliant revenue and better quality and service for members
• Understanding the various components of MA capitation and their implications for your bottom line
This program is designed for senior-level finance decision makers with leadership responsibilities for Medicare Advantage programs. This event will be advanced, but highly practical and action-oriented. As with our previous events, this program is open to health plans only. The cost of this event is $995; space is limited to 60 for this exclusive event. Pre-register now to secure your plan's attendance.
Click here to pre-register
Click here to view the preliminary agenda
If you're in Medicare Advantage these days you're a gambler, so come to Vegas and we'll show you how to win now that the rules have changed.