CenseoHealth & GHG: Retrospective Review Poll Results

July 28, 2011
|In Risk Adjustment
|By GHG Advisors

Drum roll please…

Question: What percentage of your membership are you targeting for retrospective evaluations?

Answers:                                                                                                              Prof. McCallum Report Card:

32% of webinar attendees said 80-100% of members                              B-
Far too large a net is being cast and possibly too much money spent on charts that are not yielding much clinical or financial impact.  Let’s focus this and use stronger analytics to reduce this number.
Remember only 60% of HMO & PPO members actually have an HCC.
**Score: B
If you are a dual SNP, this may be a reasonable starting point but even this volume should be reduced as your evaluations increase.

20% of webinar attendees said 65-79% of members                                B
This is a good foundation but as you increase your prospective evaluation this volume should continue to drop. Retrospective review doesn’t impact HEDIS or STARS so pushing more work over to evaluations will have a great result across your health plan with the right evaluation partner.

25% of webinar attendees said 50-64% of members                               B+
This is an excellent foundation if you are targeted 25-30% in member evaluation for 2010. Continue the good work and reduce this volume next year as you increase the evaluations

8% of webinar attendees said 35-49% of members                                  A
If you are targeting, 30-50% in member evaluations for the same year this should cover the bases. If you aren’t, you may be not accurately reporting the health status of your members and missing needed premium to cover the medical expense for next year.

15% of webinar attendees said Less than 35%                                         A+
If you are targeting, 60-100% of your membership for evaluations in the same year, feel safe and confident in this approach. If not, increase your evaluations immediately because you have not capture your membership’s health status.

Facts to remember:
• Charts may be difficult to find during RADV
• Retrospective review does not impact HEDIS, STARS, medical management, plans of treatment or medical home strategies or scores
• On average in a HMO, POS, or PPO Medicare Advantage population only 60% of the members have an HCC (don’t over review your population)
• It is not cost effective to review charts to find suspect charts; improve your analytics
• Providers work with multiple health plans with both risk adjustment and HEDIS chart review needs. Try to knock on their door as infrequently as possible.