Here Comes a New Request Wave:

Commercial Risk Adjustment

Presented by:

Jeannie Hennum

Senior Vice President of Sales & Account

Management, ChartSecure

Topics

• Risk Adjustment: Why the Need for the Chart

• Following the Money Trail: CMS, Health Plans, Providers

• Who Has the “Best” Charts: Why Facility Charts are so

Valuable

• What Needs to be Provided: Minimum Necessary

Documentation

• When Do Chart Request Waves Hit: Health Plan Request

Periods and CMS Filing Dates

• Preparing for the New Wave: What Tools are Available and

How to be Ready

2

What is Risk Adjustment?

• Program Developed by Centers for Medicare & Medicaid

Services (CMS)

• Medical Records Reviewed to Determine

Patients’ Chronic Conditions

Diabetes

Cancer

Hypertension

• Audit Results Determine Health Plans’ Compensation

• Additional Compensation to be Used for Patient Care

3

Risk Adjustment: Medicare

CMS Medicare Advantage Risk Adjustment

Time Frame: January – December

• 16.1 Million Enrollees (Annual Average Growth of over 1,500,000)

• Better Ability to Manage Patients’ Chronic Conditions

• Audit Results Determine Health Plans’ Compensation

Filing Dates:

• Medicare Advantage Plans: January, March & September

• January is the Major Filing Date (Prior Year Dates of Service)

Why Participate? It’s About the Patient – Health Management

Financial Impact on Providers? NO

• RADV (Risk Adjustment Data Validation) – Major Financial Impact on

PLANS

Documentation Required: Dates of Service Changes Annually 4

Risk Adjustment: Medicaid State Medicaid Risk Adjustment

Time Frame: January – December

• Individual State Programs

• States’ Review of Health Plan’s Compensation

• Shift Towards Medicare Advantage Risk Adjustment Model (2013)

• Audit Results Impact Enrollment Distribution

Filing Dates:

• Generally: January & September

• Varies by State

Why Participate? It’s About the Patient – Health Management

Financial Impact on Providers? NO

Documentation Required: Dates of Service Changes Annually

5

Risk Adjustment: Commercial

Commercial Risk Adjustment –

The New Wave!

Time Frame: January – December

• Centers for Medicare & Medicaid Services (CMS)

• 8 Million Enrollees

• Better Ability to Manage Patients’ Chronic Conditions

• Audit Results Determine Health Plans’ Compensation

Annual Filing Date: April 30

Why Participate? It’s About the Patient – Health Management

Financial Impact on Providers? NO

Documentation Required: Dates of Service Changes Annually

6

The Risk Adjustment

Money Trail

• Medicare Advantage

• Base Fee Per Member

• Additional Compensation for Chronic Conditions

• Example: $500 Base + $500 Cancer + $500 Diabetes

• Additional Funding – CMS

• Funds Used for Patient Care (Provider Payments)

• Commercial

• Base Fee Per Member (CMS)

• Insurance Premium (Member)

• Health Analysis of Plan’s Membership (Annually)

• Additional Funding – Payment Transfer between

Plans (managed by CMS)

• Funds Used for Patient Care (Provider Payments) 7

Who Has the Best Charts:

Hospitals!

Different Methodologies for Selecting Medical Records 1.Hospital Inpatient/Outpatient

2.PCP Specialties – Family Practice, Internal Medicine, Geriatric Medicine, General Practice

3.Endocrinology

4.Nephrology

5.Cardiology

6.Oncology, Hematology

7.Neurology

8. Infectious Disease, Pulmonary Disease

9.OB/GYN

10.Orthopedic Surgery

8

What Needs to Be Provided:

Documentation

Hospital Inpatient:

For hospital inpatient stays a medical record reviewer should code the

principal diagnosis and … all conditions that coexist at the time of

admission, that develop subsequently, or that affect the treatment received

and/or length of stay. Diagnoses that relate to an earlier episode which have

no bearing on the current hospital stay are to be excluded.

The required medical record documentation should include, but is not limited

to, the following:

1. Face sheet

2. History and physical exam

3. Physician orders

4. Progress notes

5. Operative and pathology reports

6. Consultation reports

7. Diagnostic (radiology, cardiology, etc.) testing reports

8. Discharge summary

ICD-9-CM Official

Guidelines for

Coding &

Reporting

9

What Needs to Be Provided:

Documentation

Hospital Outpatient and Physician:

Hospital outpatient and physician office

medical records should include, but are

not limited to, the following:

1. Face sheet

2. History and physical exam

3. Physician orders

4. Progress notes

5. Diagnostic reports (to support

documentation)

6. Consultation reports

10

Request Waves: Risk Adjustment

& HEDIS PROJECT TYPE January February March April May June July August September October November December

Medicare Advantage

Risk Adjustment

(RA)

HIGH MEDIUM

LOW LOW LOW MEDIUM MEDIUM MEDIUM

MEDIUM HIGH HIGH HIGH

HOSPITAL FOCUS SWEEPS SWEEPS SWEEPS

Health Effectiveness

Data & Information

Set (HEDIS) LOW MEDIUM HIGH HIGH

HIGH

LOW LOW LOW LOW LOW LOW MEDIUM

CLINIC FOCUS FILE 5/15

Medicaid RA &

HEDIS HIGH

LOW MEDIUM HIGH HIGH

HIGH

LOW MEDIUM

MEDIUM

HIGH HIGH HIGH

HOSPITAL & CLINIC

FOCUS RA FILING HEDIS FILING RA FILING

Commercial MRA

HIGH HIGH HIGH

HIGH

LOW LOW LOW LOW LOW LOW LOW LOW HOSPITAL & CLINIC

FOCUS FILE 4/30

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Preparing for the New Wave:

Solving Pain Points

1. Significant Increase in Request

Volume

2. Phone Calls, Faxes & Mail

3. Data Entry into Audit Tracking

System

4. Duplicate Requests & Incorrect

Lists

5. Accommodating Unknown, Third

Parties

6. EMR System Partitioning

7. Delivery Acknowledgement

8. Re-use of Chart

9. HIPAA Concerns

10. Impact on Administrative

Expenses

“78 inches copied, and

that was only the

beginning!”

PROVIDER

FRUSTRATION 12

Best Practices for Easing the

Burden

Centralize Medical Record Request Receipt Process Assign Receiving & Logging Requests to One Department

Verify the Request Letter for Specifics versus Entire Record NCQA Documentation List by Measure for HEDIS CMS Documentation List for Risk Adjustment

Utilize Electronic Receipt of Requests Chart Chase List Direct from Health Plan

Upload into Workflow System

Establish Electronic Delivery to Health Plans Include Receipt Acknowledgement

Understand Health Plan Filing Dates Additional Time May Be Available for Processing Large Volume

Requests

Electronic Requests

Accepted by 1/3 of the Nation’s Hospitals

13

What are the Results?

Request Centralization = Reduction of Administrative Expenses Duplicate Detection

Basis for Actionable Reports – Who is Requesting & for What Purpose

Request Letter Verification = Minimum Necessary Documentation Ensures Appropriate DOS and Chart Sections are Released

Electronic Requests = Data Integrity Eliminates Manual Data Entry

Removes Unknown Third Parties

Electronic Delivery = Better HIPAA Compliance True Proof of Delivery

Health Plan Filing Dates = Improved Resource Allocation Ability to Plan for “Request Waves”

14

How To Implement: Internal

Resources or Outsource?

Establish Program Contacts

Name, Email, Fax, Phone

Create a Shareable Locations List

Name, Address, Phone & Fax Numbers, NPI and/or Tax ID

Define any Processing/ Special Handling Rules

Requires Electronic Delivery; Attestation Forms; Specific DOS Required

Communicate Procedure Change Internally and Externally

Notification Letter to Health Plan Provider Relations

Enlist a Health Plan Advocate

Risk Adjustment and HEDIS expertise

Establish Import Routine for Electronic Requests

Review Managed Care Contracts

Copy Fee Applicability

Questions/Answers

HealthPort ChartSecure

Jeannie Hennum, Senior Vice President of

Sales & Account Management, ChartSecure,

770-360-1870, Office; 678-995-1263, Cell

jeannie.hennum@healthport.com

www.healthport.com 16