On OIG focus areas:
“For us, top of mind, we are looking at fraud, waste, and abuse by both providers providing services under plans and also at the plans themselves…We are looking at risk adjustment at the plan level and we also know there are vendor issues through the False Claims Act cases, audit work, and studies we are doing. We are continuing to look at where are those risk areas, where are the places that are problematic and focus the resources on those. For every $100 HHS spends, we only have two cents. We have a small amount of money to work with, so we focus resources on our highest risk areas.”
- Megan Tinker, chief of staff at the Office Inspector General, during the Keynote Fireside Chat: A Conversation on MA Compliance
On the changing health care landscape and need to establish organizational alignment:
“From Stars and quality perspective, change is absolutely necessary. Evolution is a requirement for successful performance improvement and to address weakness. Changes continue to come our way, and while necessary, it’s very challenging to figure out how to align within organizations and outside of them. It’s no small feat…There is not a single solution to address all of this. But it does create a requirement for a holistic approach. Solutions need to be empowering, bidirectional, and have elements of savviness to elevate experience and relationships.”
- Jaye Johnston, vice president, Stars operation, Clover Health, during the Leadership Panel: Practical Advice for Positioning Your Plan for Success for 2023 and Beyond
On the introduction of AI into risk adjustment workflow:
Prior to the introduction of AI, Blue Cross Blue Shield of Massachusetts’ 11 coders would code chart by chart. Each coder was able to code 100 to 150 charts a week, collectively 6,000 a month. The first week using AI for first-pass chart reviews, it took the team 14 days to code 9,000 charts.
“When most people hear AI, they think ‘we are going to lose our jobs, machines are going to take over.' That was the scariest thing to the team when introducing them to AI. They thought we wanted to replace them as coders. I said, 'it’s not a replacement, you are the expert. The solution needs you…AI looks at the back end and reads through the charts for you. It only shows coders what’s valuable so we don’t look at a chart that doesn’t give us any value'…Once they began to trust the system and trust the prediction, they don’t want to go back to the old days of looking through the chart page by page…With AI, it shows you the HCC or opportunity to look at the HCC and tell me if there is enough evidence for it. They love that approach. Using AI allows you to focus on one HCC so coders’ accuracy are 97 to 100 percent.”
- Mia Bell, sr. manager, Medicare & commercial risk adjustment, Blue Cross Blue Shield of Massachusetts, during the track session, Enhancing Risk Adjustment Operations with AI
On member engagement:
Forget texting and applications on smartphones—at least one Medicare Advantage member advocates reaching out the old-fashioned way: with a simple phone call.
“Call and talk to the person, it’s not difficult.”
- Carlos, a long-time member of a United HealthCare Medicare Advantage health plan, during the Patient Focus Panel: How Plans and Providers Can Positively Impact Member Experience
On reaching out to veterans in need:
“Healing is such a personal journey…At Wounded Warriors, our logo is a service member carrying another service member. At some point we all need or might need to be carried. At one point I was carried because I needed help. I am at the point now where I can be the person to carry the next veteran that needs help. All of us live that logo and that’s what makes the Wounded Warriors Project very special. We’ve all been there. We’ve struggled. We’ve persevered. We may not be at the top, but we are not six feet underground and we are here to help the next veteran who needs help. We are there to help carry them.”
- Nick Morrison, a veteran of the U.S. Marine Corps Reserve and a speaker for the Wounded Warrior Project, during the panel discussion, Serving the Veteran Population