by RISE
19. May 2010 19:30
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
