News

Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan.... Read More

 

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ... Read More

 

Why Does Risk Adjustment Need Technology?

Cognitive computing. Machine learning. Natural language processing. Two years ago, few people in the risk adjustment world had ever heard of these terms, and yet today they are becoming synonymous with risk adjustment. What are these technologies? Why do we even need them in risk adjustment? Traditional risk adjustment just isn’t efficient Traditionally, risk adjustment has been done manually: Coders comb through thousands of pages of patient charts and look for documented chronic conditions. But this isn’t the most effective or efficient process. It is time consuming and costly, and it doesn’t make good use of coders’ expertise. When I coded this way, It was frustrating that I had to spend so much time organizing my work before I could actually start doing it. Additionally, coders are often beholden to the slow and disruptive chart retrieval process.... Read More

 

Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago.... Read More

 

21st Century Cures Act: Medicare Advantage Impact

Review of Relevant Provisions with Expert Insight. March 2017. PULSE8 is privileged to bring you a summary of key Medicare Advantage program requirements within the 21st Century Cures Act. The bill was signed into law on December 13, 2016 by President Barrack Obama. Key Medicare Advantage Requirement Update Announcements: Issuance of Risk Adjustment Methodology Change Requirements (Expanded Detail Below) Order for a Temporary (through 2018) Stay of Plan Termination for 5-Star Program Underachievers Mandate to Allow Medicare Advantage Enrollment for ESRD Beneficiaries Implementation of a 3-Month Open Disenrollment Option for All Beneficiaries RISK ADJUSTMENT METHODOLOGY CHANGE REQUIREMENTS: Full Impact to be Phased-In over Payment Years 2019 through 2022 ACCOUNT FOR AN INDIVIDUAL’S TOTAL NUMBER OF CONDITIONS The Cures Act instructs the Secretary of Health and Human Services to improve the determination methodology of a beneficiary’s health status by factoring in the count of an individual’s total conditions. Furthermore, additional adjustments are to be applied as an individual’s total number of conditions increases. In practice, these changes will raise risk capitation payments, on a sliding, “HCC count per beneficiary” scale. Pulse8 foresees the development of a multiplier variable applied to an individual’s calculated HCC risk factor. The multiplier ... Read More

 

Winning in Risk Adjustment Five Steps for Health Plan Executives to Boost Coding Accuracy and Efficiency

Executive Summary An educational whitepaper, courtesy of Talix As the healthcare industry continues to shift from volume-based to value-based reimbursement, health plans are moving to change the way they do business. Recognizing that the cost of and incentives associated with traditional fee-for-service care are unsustainable, they are expanding their risk-based contracting efforts and seeking out more innovative ways to help providers deliver better care at a lower cost. For these payer organizations, accurate and timely risk adjustment is crucial to their success, as it has a direct impact on both plan revenue and care quality. The stakes are high and will only continue to grow. In today’s highly regulated, competitive and increasingly quality-focused market, payers must look to technology for cost-effective ways to expand their risk adjustment strategies. This white paper outlines the risk adjustment challenges health plans face and how technology-enabled data analytics can help plans tackle the problem and master risk adjustment through five proven steps for improved coding efficiency, productivity and accuracy. A Changing Marketplace... Read More

 

Final Report: RISE RAPS EDS Data Study

The final report for the RISE RAPS EDS Data Collaboration Study is complete and available for download and distribution. This completes more than a year of work involving 8 MA Organizations with over 30 H contracts, covering more than one million members. It has been presented at a briefing on Capitol Hill in Washington D.C. by Tom Kornfield from AHIP, Dr. Christie Teigland from Avalere and Arati Swati from Inovalon. ... Read More

 

Listen to Webinar on RISE RAPS/EDS Data Study Report

Originally broadcast on February 21 at 1:30 p.m. ET Dr. Christie Teigland, from Avalere, and Arati Swadi from Inovalon, presented the findings from the RAPS / EDS data collaboration study. The collaboration, sponsored by the RISE Association, involved eight Medicare Advantage companies with 30 H-contracts and over one million MA members. ... Read More

 

RISE RAPS-EDS COLLABORATION RESEARCH PROJECT EXECUTIVE SUMMARY

Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS). Centers for Medicare and Medicaid Services (CMS) intends to transition gradually to EDS-based payments, starting with 10 percent of the payment based on EDS in 2016, increasing to 25 percent in 2017 and 50 percent in 2018. ... Read More

 

RISE RAPS EDS Collaboration: Inovalon Presentation

The RISE technical business partner, Inovalon and their subsidiary, Avalere, conducted a RISE webinar on June 23, reporting their findings in the analysis of 2014 RAPS and EDS data for the RISE collaboration. Their slide presentation is provided below: ... Read More

 

HCC Coder Survey: Profile of the Community

Early in 2016, RISE was approached by one of the association sponsors, Apixio, about conducting a survey of the HCC coder community. They wanted a better picture of the way the coders work and the tools they use in their jobs. As a technology company, of course, Apixio was keen to understand to what extent the community is comfortable with and uses technology in their daily jobs. RISE felt that this would be a useful survey as a mirror back to the HCC coding community about themselves and how their peers work. RISE supplied a mailing list of known HCC coding members for the purpose of inviting them to participant in this study. No marketing was permitted, just the profiling survey. Here are the results, which we promised we would share with you. We hope you find it of interest. Please let us know if you have questions and we will facilitate getting answers for you. ... Read More

 

RISE to Publish RAPS to EDPS Findings: Get the Scoop!

Those of us who participated in the call with CMS on Thursday morning heard that there are problems rolling out this transition from RAPS to EDPS and that CMS is closely focused on the issue. However, the healthplans included in the RISE RAPS to EDPS transition data collaboration are already way ahead on this topic. I am very pleased to announce that RISE will be publishing the results of our study shortly... Read More

 

Some Notes on the RISE Nashville Summit 2016

by Kevin Mowll, Executive Director of RISE. The bigger this annual event gets, the more difficult it is to summarize all the themes and nuggets of information. Perhaps the most useful place to start is with the keynote address by Senator Tom Daschle and some of the key ideas that emerged from the RISE Advisory Board meeting on Sunday, with thanks to Denise Tortora, our RISE / Healthcare Education Associates senior vice president of marketing for her notes, as well.... Read More

 

CMS Found to Underpay for Duals with Chronic Conditions

A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions. CMS uses a risk adjustment model to determine its payments to plans based on the expected healthcare costs of each plan’s enrollees. This process is known as risk adjustment. Avalere finds that CMS’s risk adjustment model under-predicts costs for individuals with multiple chronic conditions by $2.6 billion on an annual basis. CMS last updated the model in 2014 and has indicated that it will make changes to the model intended to improve its accuracy for certain Medicare-Medicaid “dual eligibles” in 2017.... Read More

 

News Flash! CMS Delays MA Sweeps Deadline by Three Weeks

We have a report that CMS extended the sweeps deadline by 3 weeks today. An executive at one of our RISE affiliated health plans met with CMS on Monday and explained the impact of the new 410 edit which caused a surge in rejects for 2014 RAPS data. CMS graciously decided to rescind the edit and allow everyone an extra 3 weeks. ... Read More

 

Is Ambiguity Our Friend Any More? (Redux of July 15)

By Kevin Mowll, Executive Director of the RISE Association HCC coding is a rigorous and demanding science, as I have learned from the coding workshops RISE has put on for coders. There are admitted “grey zones” where different coders come up with different conclusions on which codes are allowable and which are riskier bets. This ambiguity allows payers with higher tolerances to “sail closer to the wind” when it comes to policy decisions regarding HCC coding. It permits them to harvest more diagnoses and the revenue that they bring, which does all kinds of good things for maintaining rich plan benefits and lower premiums to compete in the market. Isn’t that a good thing? Well, maybe not.... Read More

 

ICD-10 Coding and GEMs

By Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP The General Equivalence Mappings (GEMs) are a series of crosswalks created by CMS to help all organizations dealing with the ICD-10 transition translate from ICD-9 to ICD-10 quickly and easily. Unfortunately, many organizations have simply installed the GEMs into their coding or billing systems without understanding the implications of doing so. This is an invitation for inaccurate coding. The GEMs cannot be relied upon for complete and accurate coding. All coders should rely upon the ICD-10 book(s) or an officially certified electronic resource when selecting ICD-10 codes. Coders should utilize the process they were taught at the beginning of their training: seek the diagnostic terminology in the index, review the tabular for any special notes and to confirm code selection, then assign the code. There are nearly 70,000 diagnosis codes in ICD-10. The vast majority of these (over 90%) are different in their specific language than ICD-9 codes. According to the AAPC, a recent study noted 445 instances when a single ICD-9 code can map to more than 50 possible ICD-10 codes; and 210 instances where a single ICD-9 code can map to more than 100ICD-10 codes (Healthcare Business News, Nov. 2015). It is impossible for an automated system to accurately and correctly assign ICD-10 codes. CMS concurs with this recommendation. In their GEMs FAQ document, the organization notes that,... Read More

 

Where To Now on the HIX Marketplace?

It appears that there is a popular backlash against the reforms that HHS wants to conduct in the HIX marketplace outlined in their proposed rules. The following Modern Healthcare article suggests that the overriding issue that the public is concerned about is achieving some kind of stable path for premiums and the elimination of the big swings from one year to the next. HHS, in contrast, is trying to impose some restrictions and uniformity like CMS did in the Medicare Advantage world: regulations around what a provider network can look like, standardized benefit packages (not just actuarial values), and so on. The payer community objects to such restrictions which, they claim,... Read More

 

CMS Comes Out with EDS Filtration Logic

CMS has just published the final version of the filtration logic for the EDS data submissions. This is the long-awaited set of specs for the risk adjustment community in Medicare Advantage plans. You should have this coming to you now via your HPMS system. Feel free to contact me if you do not have the pdf document and I can e-mail it to you. ... Read More

 

The Health Insurance Exchanges RADV Audit Process

By Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP. For health plans (insurers) participating in the Health Insurance Exchanges (HIX), one important aspect of the program is the Risk Adjustment Data Validation (RADV) audit. RADV audits have existed for several years in the Medicare Advantage program, but there are several important differences in the HIX (“Commercial”) sphere. While the 2015 Commercial RADV audits were indefinitely delayed and ultimately foregone, HHS has indicated its intention to begin ... Read More

 

Gamification: The Realities of the Health Insurance Exchange Marketplace

I just returned from the fall Risk Adjustment Forum in Ft. Lauderdale with a greater appreciation of the perils of risk adjustment in the HIX marketplace in contrast with the Medicare Advantage world. Then right on the heels of that, we noticed the headlines in Modern Healthcare that United HealthCare is having second thoughts about remaining in the HIX game due to $425M in losses. Imagine that your HIX program invested a “chunk of change” in risk adjustment activities like you might under a Medicare Advantage plan... Read More

 

Risk Adjustment on the Health Insurance Exchanges

Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP October 26, 2015 In early 2014, DHHS introduced the concepts of Risk Adjustment for the Health Insurance Exchanges (HIX). Despite the intervening months, there remain a large amount of confusion and some lingering questions regarding the details of this program. Risk adjustment exists in the HIX sphere (also known as Commercial or HHS Risk Adjustment) for the same purposes that it was instituted into Medicare Advantage: to protect against adverse selection and mitigate the financial impact of healthy versus unhealthy members. Without the incentive of risk adjustment, health plans have traditionally selected for healthier members, who cost them less. ... Read More

 

Insights from the HCC Coding Accuracy Workshop: Physician Engagement

I had the opportunity to participate in the RISE Risk Adjustment Academy workshops in Boston on October 21 and 22. Both workshops were great and I found myself taking a lot of notes. As I absorbed the information from the HCC Coding Accuracy program in particular, I realized some insights about HCC coding that were new and exciting to me. One of the ideas was about the frequent disconnect between physicians and coders. Others brought up this topic before but it received extra attention in our workshop and was clarified for me by Donna Malone, one of our terrific faculty members from the Tufts Health Plan in Boston. The physician mind is focused on the associated process of evaluating, treating and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language... Read More

 

Update on RISE RAPS / EDS Industry Collaboration with Inovalon

Closing Off Contracting Shortly! The industry collaboration that RISE has pioneered with several healthplans is making significant progress with business partner, Inovalon, under Jason Rose's leadership. There are several MAOs now confirmed for participation in the joint study project, some in final contracting stages, putting the aggregated MA membership at roughly 500,000 and climbing. Given the CMS announcement that they plan to publish the final MAO-004 filtration guidance in December, we have taken a few more weeks to recruit as many healthplans into the project as possible. The project support provided by Inovalon has enabled us to continue discussions with plans that expressed interest and bring them onto the project. We will be wrapping up recruitment by approximiately October 31... Read More

 

A Risk Adjustment Education Webinar Series from Richard Lieberman

The only comprehensive risk adjustment education series for health plans, exchange issuers, ACOs and risk-bearing provider groups from Mile High Healthcare Analytics A true deep dive into the critical issues facing risk adjustment programs today. This is not a high-level 101 version of risk adjustment, it is aimed at decision-makers looking for practical advice on how to optimize their operations quickly. Delivered online, this is the perfect series to fit into your busy schedule and to avoid expensive travel costs.... Read More

 

The Certified Risk Adjustment Coder (CRC)

The Certified Risk Adjustment Coder (CRC) is the only certification testing competencies for coders under all risk adjustment models. As risk adjustment payment models gain more momentum, it is important for coders to demonstrate expertise in diagnosis coding for proper risk adjustment determinations. Professionals with the CRC certification demonstrate proficiency with documentation review, determining conditions that qualify for coding, assigning the proper ICD-9-CM diagnosis codes ... Read More

 

How to Choose an Initial Validation Auditor

The Health Insurance Exchange Marketplace has already pre-sented a number of challenges to the Qualified Health Plans (QHPs) or issuers on and off the exchange. The latest obstacle to overcome is the Initial Validation Audit (IVA) and the required selection of a qualified IVA vendor. The intent of the IVA, quite simply, is to ensure that the membership and risk adjustment information being sent to HHS for payment is accurate and com-plete. The purpose of this white paper, therefore, is to help QHPs know what to look for (and what to avoid) when selecting their IVA vendor.... Read More

 

RISE Industry Collaboration on RAPS to EDS

Today we broadcasted a webinar that presented the RISE Industry Collaboration on the Medicare Advantage migration from a RAPS-based method over to an encounter data system (EDS) for creating the Risk Adjustment Factor (RAF Score) beginning in 2016. This collaboration is an industry-wide effort to gage the effect of switching to an EDS method and how that impacts the CMS premium levels for MAOs. Inovalon has offered to serve as the technology partner supporting this analysis, and our presentation today walks the audience through the purpose and methodology proposed. We aim to identify MAOs that want to participate by August 31 so we can commit the resources to conducting and completing the study by the end of December this year. ... Read More

 

Dear Doctor: the OIG Thinks We Owe Them $12.2 B

The Department of Health and Human Services has done some numbers on payment accuracy for federal programs. Well, "inaccuracy" is actually what they were talking about. Among a short list of "high-error" programs, Medicare Advantage Part C gets tagged with an 8.5% improper payment rate, which translates into $12.2 B estimated for payment year 2014 (down from their estimated 15.4% error rate in 2009). ... Read More

 

Is Ambiguity Our Friend Any More?

I have heard from some plans that they relish the flexibility that ambiguity grants them to “sail closer to the wind” when it comes to policy decisions regarding HCC coding. It permits them to harvest more diagnoses and the revenue that they bring, which all kinds of good things for maintaining rich plan benefits and lower premiums to compete in the market. Isn’t that a good thing? Well, maybe not.... Read More

 

News Update on CMS RADV Findings

Center for Public Integrity Publishes Latest News on RADV Audits Fred Schulte published the most recent article in his continuing series regarding the Medicare Advantage risk adjustment data validation audits. Check out the article: http://www.publicintegrity.org/2015/07/10/17634/more-medicare-advantage-audits-reveal-overcharges Based upon the results from a Freedom of Information Act filing and subsequent court order, it appears that CMS has released some information that previously was unavailable to the public regarding four healthplan audits, in addition to one recently released regarding PacifiCare of Washington. The key issue here is the CMS findings regarding the failure of chart audits to validate the diagnosis originally submitted to CMS in RAPS data. ... Read More

 

Fred Schulte Asks, "Why Not Extrapolate?"

If you have missed his series of articles in the Center for Public Integrity website, you will want to make his acquaintence with his appearance on an National Public Radio article (see link below). I received a call from Fred last week and we explored the issue of extrapolation penalties for Medicare Advantage RADV audits. In short, Fred's contention is that there is "upcoding" of procedure codes for FFS Medicare billing that is subjected to OIG audits and subsequent extrapolation penalites, which should be the same standard applied to diagnostic "upcoding" under Medicare Advantage. This means that any errors discovered in a RADV audit would be subject to a penalty that is extrapolated across the whole population: chart audit confirmation of diagnostic codes would have zero tolerance for non-validation. ... Read More

 

CMS RADV Q&A Document

I noticed the link to the CMS RADV Q&A that Tam Pham mentioned today in her webinar presentation on CMS RADV PRocess Overview and Best Practice ... Read More

 

Where Coding Takes Us

Risk Adjustment and Controversy: Risk adjustment is a payment tool that is coming under greater levels of scrutiny, particularly given some recent journalism that presented a very slanted view of the practice as it relates to the popular Medicare Advantage program that provides health coverage to roughly 30% of Medicare beneficiaries. While this series of articles is critical of the health insurance industry, it mixes a string of worthwhile and valid points with a large dose of bad information and invalid accusation (http://www.publicintegrity.org/). Putting this into perspective requires more than tough soundbites. It requires some understanding of what the government and the industry are really trying to do and how they are going about it. ... Read More

 

Medicare Advantage Money Grab: More whistleblowers allege health plan overcharges

Jim Swoben and I have been exchanging LinkedIn postings. We agree that, where there is fraud involved, let the hammer fall. However, where this series of articles by Fred Schulte goes involves some expanded definition of what is fraud and what is appropriate risk revenue management. That is where we are going to disagree about this, as Jim and I have discussed. So let's first get our terms and definitions straight. Fraud involves intentional and knowing extraction of funds to which you are not entitled, perhaps even through careless negligence as a responsible and accountable player. ... Read More

 

Redefining Member Engagement

Today, it is especially critical for Health Plans to develop a solid plan and execution strategy for driving member engagement and loyalty. Health Plans acknowledge that it is more cost effective to retain first year members as opposed to enrolling new members. In order to increase member retention rates, it is imperative to begin to effectively engage each member at the point of enrollment. In-home health assessments are typically the first engagement effort Medicare Advantage Plans provide to their members, post-enrollment. These health assessments are not only focused on collecting ... Read More

 

Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

If you have been sleeping under a rock, you may not be aware of this risk adjustment legal case in Florida. Otherwise, you are wondering how it will turn out and what it will reveal about what really went on in Del Rey, Florida. The question is really about what was done by whom, where were legal lines crossed and who all is going to end up paying the piper. ... Read More

 

RISE Nashville 2015 Hit a Home Run!

What a pleasure to report on last week’s event at the Gaylord Opryland convention center! First, it was the largest event in HEA’s 9 year history featuring RISE. We had over 850 registered in contrast with 600 last year and 450 the year before. Needless to say, we were thrilled with the turnout. Aside from scale, however, what really stood out was the content and speakers in a combination of general sessions (chaired by Nathan Goldstein from Censeo Health) and four concurrent breakout sessions that covered several themes ... Read More

 

Is There a Grey Zone in HCC Coding?

In an insurance world where financial underpinnings are tied to risk, the industry tries to create a science of risk assessment (in the generic sense) so they can price against it with confidence. This has worked historically for life insurance, for example, and in the indemnity health insurance markets, as well. But in today’s health care world, there are points of confusion about risk adjustment coding used to calibrate premiums, as in Medicare Advantage, or to redistribute them, as in the health insurance exchanges. When I mention the idea of “areas of grey” in risk adjustment coding, this is not to say that the coders I met are terribly confused. ... Read More

 

AAPC Risk Adjustment Certification Launced

RISE Supports the AAPC's New Certificate The large national coding certification company has launched its latest certificate program, risk adjustment coding. For those involved in risk adjustment coding for some time, the medical coding certificates for provider office practices and other settings did not fully embrace the work they were doing. Now a standardized program of study and preparation is available through AAPC, including an online training... Read More

 

Does the Public Believe the Headlines?

This article is very disturbing. It is so easy to hate insurance companies and assume that this is all true without understanding the more complex story. I think we risk getting the "baby thrown out with the bath water" if we cannot spell out the value of risk adjustment and accountable care, compared with the failings of FFS healthcare. ... Read More

 

Smart Analysis of CMS Advance Notice

Pulse8 provides a valuable summary and keen analysis of the advance notice, featuring key insights they want to call to our attention. Their analysis parses out some critical factors that you really need to understand and to which you should pay attention. I recommend that you download this and spend some time digesting its crucial take-aways. ... Read More

 

Following Up on the 2016 CMS Advance Notice

Mintz Levin Alerts MA Organizations About Fraud Risks In the article written by Tara Swenson of Mintz Levin and published in the National Law Review recently, there are some worthwhile points to note. First, that CMS is now viewing the population of Medicare Advantage members as being no different than those beneficiaries in Original FFS Medicare, on the whole. Therefore, the logic goes, the aggregate payment level show be equivalent to the "old school" AAPCC model used before the year 2000 (BIPA era, for the old schoolers). This has some very important implications I will talk about below. ... Read More

 

The RISE Academy

Where can you get a comprehensive picture of how key areas of our accountable care movement work? Think about it. People that are new end up sitting next to someone else who has been there a little bit longer. Call it "sit-by-Susie" training. Is that really going to get people up to speed with a comprehensive view of what field they are working in and how their jobs fit in? What's more, when you hire people "with experience", what kind of confidence do you have that they really have the background you need? ... Read More

 

Update on CEU Credits for RISE Risk Adjustment Forum

AAPC and AHIMA Coders That Attended in Coral Gables. All H239 Certificates were sent out for the main conference, and the workshops, as well. However, due to some confusion, there are separate certificates for each. ... Read More

 

CMS Posts MAO-004 Report

Take a look at the attached report. It will give you the direction that the industry has been waiting for from CMS.... Read More

 

CMS Risk Adjustment Participant Manual 2006

This is an extremely valuable reference tool from 2006 for everyone involved in risk adjustment.... Read More

 

Coding and Documentation Takes Center Stage

RISE members are hungry for insights and guidance about coding in this world of risk adjusted health insurance. In particular, the coders are asking for opportunities to learn from those who have a grasp on deciperhing the complex and specific ... Read More

 

RADV Best Practices User Group Meeting 10/29

The first meeting took place, setting in motion a forum for exploring and sharing best practices regarding RADV programs. The scope of the user group embraces everything from risk mitigation, program design and strategies, to preparation and execution of the business... Read More

 

November 17-18 Risk Adjustment Overflow Hotel Announced!

Due to the popularity of the Risk Adjustment Forum the Westin Colonnade has sold out, thus an overflow room block been established. Do not delay book your room today as the overflow block will sell out rapidly. The overflow hotel is located just blocks from the Westin Colonnade. ... Read More

 

RAPS / EDS User Group Report

The RISE User Group aims to find out the answer to this question. It involves complexity that is difficult to appreciate until you dig in deeper. There are a lot of variables that cause different healthplans to come to different conclusions.... Read More

 

CMS RAPS Submission Dates

CMS Publishes the RAPS submission deadlines for dates of service (with thanks to RISE Sponsor, Advance Health)... Read More

 

RAPS / EDS User Group Sets Out a Course

CMS is using an encounter data submission (EDS) data extract to replace RAPS, and drive the calculation of HCC risk scores as well as related premium revenue for Medicare Advantage members.... Read More

 

Call for RAPS / EDS User Group Members

RISE is issuing a call for members to join a user group to get our bearings on the impact of the CMS changes from a RAPS-based data submission process to an EDPS methodology. This is a practical work group that will gather data and develop shared metrics to compare the effects of the conversion on future CMS premiums. ... Read More

 

The Risk Adjustment Forum for Health Plans

This event, set at the Fairmont Hotel in Chicago, was one of the most powerful and productive risk adjustment events I have attended: The presentations were strong and meaty with content The scope of the topics was geared perfectly to the target, including both Medicare and Health Insurance Exchange domains The questions and answers were often vigorous and plumbed deeper and more keenly than expected... Read More

 

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Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan....
Read More

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ...
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Quality measurement and risk adjustment regulations are increasing and the financial impact upon health plans is progressively driving accountability and influencing profitability through payments, penalties, and bonuses. To improve performance and optimize risk and quality payments, Health Plans need to streamline processes, employ best practices for data capture, and focus on strategic interventions that use a member-centric approach.  

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