Medicare RADV User Group

After talking with colleagues at our RISE Nashville conference as well as the risk adjustment forum in Chicago at the end of May, we were encouraged to create a user group for the risk adjustment leadership of Medicare Advantage plans.  These representatives included plans that had been through a RADV audit as well as those who hadn’t yet. Their interests in forming a user group were similar, regardless of whether they had already gone through the RADV experience:

  • Sharing the plans on preparation and execution once the RADV audit notice arrived
  • On-going learning around best practices, learning directly from peers and colleagues about risk mitigation
  • Easy access to peers willing to share their learned lessons and insights inside the user group calls as well as offline on an ad hoc basis
  • A comfortable place to bring questions, problem-solve or test new ideas before launching them
  • A forum to create a support network of colleagues across the country, and to form a network of friends to meet-up with at the conferences

What Is Being Discussed?

This is a new user group but we have already mapped out some topics of interest.  We will add-on, expand and evolve based on the needs of the users:

  1. What kind of organizational structure, roles and staffing do different RA organizations have?
  2. Identifying the pros and cons of outsourcing or insourcing different functions for a RADV audit.
  3. How to organize the roles and tasks in advance of the RADV audit?
  4. Once the audit notice is received, what are some best practices in project management and orchestration?
  5. What level of errors did your organization encounter?
  6. What are the most common unvalidated HCCs you came across?
  7. What is the CMS definition of the benchmark FFS error rate against which you will be rated for variance?

Who Will Be Involved?

This user group of peers will be organized mostly at the department director and manager level, but we would hope to have the leaders invite their staff and analysts to join the calls, as well.  RISE will organize and facilitate the meetings.  We will garner specific topics from the users and identify who will present or talk about the topics, apart from allowing free discussion and dialogue during the sessions.  The agendas will be managed to stick to roughly an hour time slot, unless the group feels like a longer session should be scheduled.  Also, ad hoc inclusion of other functional areas would be appropriate based on the agenda topics, such as regulatory compliance, finance, provider relations or clinical departments, for example.

 

How to Get Involved

Send us an e-mail requesting participation, the type of topics you want to discuss and we will organize the group and the meeting times.  We will reply with a link or phone number to call, the topics that the group is discussing and the meeting times.

RISE Contact:   Kevin Mowll  kmowll@risehealth.org 831-465-2283


Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

Evaluating the Results of the Enrollment Seasons

The annual review and selection of health insurance for one’s self and family has become an American tradition. During these annual enrollment periods (AEP’s, but referred to under various names), employees, Medicare recipients, and those in the individual and family markets conduct their own variations of the due diligence necessary to assure they will be in the right plan in the coming year. While consumers are pondering their options, health insurers will spend millions in the attempt to attract, retain, and enroll new members. As we near the end of the enrollment seasons, Deft Research will be fielding major national studies geared to evaluate the degree of success these efforts have produced. The research season starts with “shopping and switching” studies published in the first months of the new year, looking at the individual and family plan (IFP) market and at the individual market for Medicare-related insurance. What to look for when diagnosing AEP results Here are some of the factors Deft Research will be tracking and evaluating in 2018. Timing of Consumer Shopping. In the past, the number of seniors ...
Read More

HOW A 360-DEGREE VIEW OF RISK ADJUSTMENT IMPACTS VALUE-BASED CARE

Over the past several years, a shift towards value-based care has begun in the US healthcare system. Within value-based care, incentives and policy structures exist to prevent risk selection, where insurers try to avoid enrolling high-risk members who may be costly to cover. Risk adjustment seeks to project and correct for costs incurred by health plans to treat members of varying risk levels. The Centers for Medicare & Medicaid Services (CMS) first introduced risk adjustment with Medicare Advantage, which has been using CMS’s Hierarchical Condition Category (HCC) models to risk adjust since 2004. Medicare Advantage enrollment has been steadily growing and is expected to reach 22 million by 2020. With the move towards value-based care—fueled not only by the Patient Protection and Affordable Care Act (ACA), but also the Department of Health & Human Services’ (HHS)—a bold goal was made to have 90% of CMS payments linked to value-based care and 50% under APMs by 20181. Given this shift, risk-based payments have become more common. Today, risk adjustment also impacts Managed Medicaid plans, Qualified Health Plans under the ACA, Accountable Care Organizations, and provider groups that share risk with their health plan partners. With value-based model enrollment growth, risk adjustment is becoming increasingly important to a health plan’s success. At the same time, market dynamics are putting pressure on the risk adjustment environment....
Read More

Upcoming Conference

 

RISE Risk Adjustment Academy: CMS & HHS Risk Adjustment 101 and HCC Coding Accuracy

Designed as an introduction or refresher that covers all the bases when working with Medicare Advantage or on commercial health insurance exchanges lines of business. The workshop program is a holistic orientation to the risk adjustment panorama and deep dive into HCC coding for accuracy. With a mix of health plan and provider audiences, a powerful environment for interaction and collaboration is built over two-days. You will gain insight, tips, and best practices to build upon your knowledge of risk adjustment, coding, and documentation.

More

Upcoming Webinar

A Hitchhiker's Guide to HCCs, RAFs and More from a Payer Perspective

This webinar will provide a compelling and insightful overview of HCCs, Risk Adjustment Factors and Clinical Data. It seeks to present a clear understanding of what Payers must do to use these CMS mandated levers for improving patient care and getting appropriately reimbursed for the most severely ill patients. Join Prognos to get broad guidance on a pragmatic approach to implementing HCCs using all of the available clinical data resources including lab test results in a repeatable and streamlined process throughout the 12 month HCC reference period.

 

Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.