Exchange 2014 Data Submission Due April 30,2015
As we wind down on our inaugural year with Health Insurance Exchanges (HIX), we have seen plans using a variety of approaches in their Risk Adjustment data reporting efforts. Some continue to use the same approaches used for their Medicare programs (chart reviews, provider outreach, in-home assessments, etc). Some have not even begun any retrospective, prospective or quality programs because they don’t know where to begin. What is the right approach? Probably somewhere in the middle.
Qualified Health Plans need to be very targeted in their retrospective and prospective programs. They also need to have some type of quality assurance program in place. Although HHS has stated that “For 2014 and 2015, an initial and second validation audit will be conducted, but the findings will not be used to adjust payments.” Plans still need to be cognizant of the quality of the data they are submitting and are still subject to the False Claims Act. CMS has also stated that when medical record reviews are performed, “the issuer must evaluate all diagnoses on the original claim and the issuer must delete any diagnoses not supported by the medical record.” This is a new practice for many plans, but one that must be implemented.
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 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 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
In a webinar on Thursday, October 23, Janet Fina, GHG’s Vice President of Risk Adjustment, together with colleague, Carol Olson, GHG’s Director of Risk Adjustment, addressed areas for documentation improvement that will allow for accurate reimbursement and disease and case management opportunities. Become a member of the Point to access the recording >>
Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>