By RaeAnn Grossman, Senior Vice President, Gorman Health Group

Ask Yourself: What would my 2012 member assessment strategy and timing look like if I want to look like a Risk Adjustment Super Hero?

Step 1: Compile Data in February

Step 2: Launch Member Evaluation 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 January - June and July - December for Member Evaluations to Ensure ROI and Payment Reconciliation

We talk to health plans every day that want to internalize risk adjustment. Bottom line: It is a good idea.

Taking control and building an expert, internal risk adjustment team is one of the best tactics a health plan can take. Here, we share an initial checklist of those areas needed for “in-sourcing”:

·         Claims based HCC filtering

·         RAPS filtering and submission

·         EDPS compilation and submission

·         Medical record suspect generation

·         Medical record retrieval

·         Medical record coding

·         Chart warehouse

·         Hospital outreach for electronic encounter compilation

·         Member evaluation suspect generation

·         Evaluation development

·         Member evaluation provider network

·         Member evaluation findings integration

·         Tracking & closing gaps in care with member outreach

·         Member care report cards

·         Primary care physician medical home

·         Metrics, benchmarks, ROI, reports, and performance monitoring

Much of this you can internalize cost effectively, but you still need to be diligent. We’ve helped several health plans analyze their programs and vendors to determine what to pull in-house. Strategy, discipline, compliance and an engaged multi-disciplinary team willing to make decisions and push forward are critical elements for success.

By: RaeAnn Grossman, SVP, Gorman Health Group

What are organizations doing to direct efforts and protect revenue streams in light of CMS changes in Medicare Advantage (MA) reimbursement? CMS has begun to implement changes in payment methodology for MA organizations once again.  It seems that when MA organizations have just gotten used to risk based reimbursement, they must now reorient once again when looking at reimbursement rates.  MA organizations have just, in the past few years, completed the total transition to risk based revenue funding.  Now they must keep this in place and work on other measures that are contained in the MA Star Rating.

MA organizations revenue will no longer be strictly risk based.  Starting very soon, organization's reimbursement will not only be based on the "wellness" of members associated increased payment for sicker members, but will also be based on quality measures derived from the Star Rating system.  Organizations in the coming years will actually begin to loose payment if the Star Ratings are 3 or less.  While we can all applaud the focus on quality, there are many questions about the Star Rating that may need to be addressed: 

• Are the Star Ratings fair?
• Are the Star Ratings based on data that is too old?
• How will this new system play into the CMS Risk Adjustment Payment Audits?

Organizations must take active and immediate actions to assess and improve their Star Rating.  Data that goes into this rating may very well be old- up to a year.  Actions now for quality improvement and customer satisfaction will not be reflected immediately in your rating.  What is your organization doing to transition? Will the delay in data gathering affecting the Star Rating be detrimental to your revenue in the short run?

Let us know how your organization is preparing for this change and the measures you are taking to affect your Star Rating!

-Ann U. Greenberg, CHP, CCEP, President, AG COMPLIANCE GROUP, LLC

 Member of the Advisory Board, RISE

With the enactment of certain provisions of the Health Care Affordability Act, it is becoming very clear that the way medicine is practiced will change. As I wrote in a previous blog, one of the values of Medicare Advantage is that it has required practicing physicians to take a population based view of our practices. It has forced us to think about accuracy in coding in order to appropriately allocate resources which will ideally direct more care to those regions that need it most.

During a risk management training session, I spoke to an older physician who said that not only will he not change his 20 year old super bill or submit claims online; he plans to stop practicing immediately before Medicare begins penalizing providers for not meeting meaningful use requirements for an EMR. I believe that practicing physicians will self stratify in their willingness and ability to adapt to the impending changes of the health care landscape. It would behoove any health plan or IPA to watch this self-sorting take place and identify those practices that are geared toward future success.

Analysts have estimated that in the next decade the Health Care reform will be responsible for increases in health care costs. Not just readiness to change, but also this increase in cost will ultimately set some practices apart from others.

Dr. David Nash, chairman of the Department of Health policy at Jefferson Medical College, listed the qualities of practices that will survive into the next decade. 2 of the 4 criteria were achieving pre-determined quality based outcomes in care and maintaining transparency in practice methods necessary to achieve some standard of public accountability. Certainly, these will become objective standards that can be used to “rank” a practice in the future. The mere mention of this concept sets the teeth of many physicians on edge. Others see it as a worthy challenge.

Looking into the future, practices that are using the full functionality of an EMR for coding and documentation, are using Health Plan and IPA data to track preventive care (which will hopefully improve as health care reform removes cost barriers to preventive care); and are using Evidence based medicine to guide the care of their chronic disease populations.  These are the ones that will receive the largest increases in risk score, P4P score, and perhaps even patient satisfaction. Beginning to invest in these practices now will be of great value in the not-so-distant future.

-Dr. Preedar Oreggio, Clinical Director, SIERRA SPRING FAMILY WELLNESS CENTER

In this blog, I will share the approach Precision Healthcare is taking towards integrating case management and HCC coding. I would like any and all feedback from organizations which are: contemplating, currently undertaking or have already achieved such integration. In our experience greater than 60% of the patients identified for case management are also targeted for HCC coding initiatives. Given the limited time and attention span most physicians have when it comes to these topics, Precision Healthcare is taking a patient centric, action oriented approach to accomplishing its goals in both arenas. For each patient identified for both case management and HCC coding focus, the work flow essentially consists of the following:

1. Medical record audits by the case manager & HCC coder 
2. Interventions required by the PCP for case management and HCC coding are recorded during audits. An example of case management intervention would be for the PCP to prescribe more affordable pharmacy alternatives in order to help patients overcome financial obstacles to compliance with prescribed treatment plans. An examples of HCC coding interventions would be for the PCP to review a coding Query for patient specific diagnosis, to include PCP evaluation and detailed documentation of ongoing medical management (if any) during the next visit.  
3. Case manager coordinates the subsequent patient - PCP visit 
4. Case manager attends the subsequent patient – PCP visit, with a list of the fore mentioned interventions for PCP completion, and supports PCP in their execution.

The pursued outcomes are:

•  Patient empowerment to proactively participate in their healthcare  
• Provider education of case management & HCC coding 
• Support of provider office to achieve positive outcomes for the high disease acuity and severity population 
• Medical record documentation Quality Improvement (RADV risk mitigation) 
• Accurate future risk premiums 
• Improved quality of life for patient through subsequent continued case management monitoring and evaluation 
• Improved patient satisfaction as derivative of concierge care model

To date, preliminary results are as follows:

•  High ROI : 1.7 HCCs / Query 
• Complete results will be presented at the March 2011 RISE Annual Conference 
• Physician engagement is essential, so don’t forget the Incentive! 
• Physician support staff is key to your success

I am looking forward to hearing about your experiences in integrating, particularly how to work with FFS providers and incentive structures.

Ken Persaud, Chief Executive Officer, PRECISION HEALTHCARE SYSTEMS

RISE is proud to announce the 1st edition of "Rising to the Challenge!", our quarterly newsletter.

The July 2010 edition is a recap of topics discussed at the July 15-16 conference in Del Mar, CA: HCC Management for Health Plans and Providers

A brief excerpt:

Nathan challenged the audience to consider: Where do HCCs come from? He cited claims, charts, and the members themselves as sources of data. Claims Nathan described as a proxy; "You can mine claims, then you collect backup documentation." The chart reviews document the codes submitted and validate "suspects". "This has been perfectly good up to now," Nathan says. "But the most powerful way to find your data, is to look in your members’ bodies. You’ll get incredibly useful, real-time clinical information… information that is actionable."

But can you afford to pay for a prospective program?

Craig Bellise, Director of Risk Adjustment Management at Emblem Health, said "We’ve been doing home assessments for three years now, and have really ratcheted up our approach this year. That first year, we decided to just go for it – we ran a pilot and crossed our fingers for some kind of ROI. As it turns out that first effort yielded a 3:1 return, which made the program very viable. You’ve got to get people to say, ‘We’re going to pay for it, take a shot, and carry the expenses for a year in order to reduce our reliance on retrospective reviews, improve compliance measures and enhance the quality of the care for our members.’"

Download the full newsletter to read more!

Just one benefit of RISE membership is the opportunity for free passes to educational webinars.  On July 19th, our first RISE webinar event is a 3-part series: The Nuts and Bolts of Home Assessments.

The series address the entire home assessment process from beginning to end, including:

• Preparing for success: Operational requirements, resource allocation and program set up
• Executing the actual home assessments: Documents, procedures and communications
• What to do after completing prospective assessments: Closing the gap between risk management and medical management

Click "register now" button on the left side of your screen to grab one of the few remaining free passes -while they still last.

In the current Medicare Advantage (MA) environment, health reform promises Medicare beneficiaries improved quality of care, reduced costs, and a solvent Medicare program for the future. The 2011 CMS Call Letter, confirmed continued downward MRA coding intensity adjustments, making it more difficult for most MA plans to keep pace with the increasing costs of healthcare.

The CMS Star Rating system will make the MA industry accountable for demonstrating value based healthcare delivery, at a time when significant reimbursement cuts are on the horizon. The race to develop a strategic business plan to support development of innovative quality improvement programs and a successful prospective risk adjustment program is paramount to the survival of MA plans in 2012 and beyond. Plans currently relying solely on medical claims and retrospective MRA reviews, will find themselves losing ground to the continued coding intensity adjustments, and be faced with the difficult decision of reducing member benefits and becoming less competitive. So why is a prospective risk adjustment program the solution? And why is it critical that plans begin Due Diligence now?

A prospective risk adjustment program is defined as an established outreach program to patients and their respective physicians, at pre-established intervals for the purpose of coordinating comprehensive health risk assessments (HRA). The content of the HRA, is of vital importance and should be customized to meet the needs of the medical management and risk adjustment programs for the plan at the time of implementation. The primary objectives of a prospective risk adjustment program are:

To conduct a comprehensive annual update of the patient’s medical record to include all existing and past medical conditions, review of current medications, documentation of current treatment plans, appropriate functional assessments, and to schedule preventive health screenings (star rating impact).

To identify "Best Practices" through integration of clinical programs and the risk adjustment programs, to improve health outcomes and ensure timely premiums for plan members.

To report accurate risk adjustment information to CMS on time for CMS sweeps, and thereby ensure premiums which will allow continued revenue allocation towards continuous quality improvement initiatives.

To generate referrals to case management and disease management, based on identified patient specific health risks, and to avoid adverse health outcomes (star rating impact).

To educate members with respect to the importance of adherence to prescribed treatment plans and to create a member experience which will pay dividens, as a member retention strategy (star rating impact)?

To document the medical management of all existing patient specific medical conditions in a manner that satisfies the CMS risk adjustment Data Validation criteria, thereby mitigating plan exposure to RADV audits.

To communicate HRA information to treating physicians, in order to promote coordination of care, and to convert a reactive healthcare system, into a proactive one.

Whether plans decide to partner with a vendor or conduct a prospective risk adjustment strategy internally, coordinating the people, processes and technology necessary will be extraordinarily complex. None the less plans must rise to the challenge, as it is the Medicare Advantage industry’s opportunity to demonstrate its value to CMS.

-Kenneth Persaud, Director of Network Management, PHYSICIANS UNITED PLAN HMO