Initial Validation Audit Pilot - cognisight.com · •Pair-wise test compares SVA and IVA results ... • Prior to official results – review IVA results • Discuss with IVA any

©2017 Cognisight, LLC

Initial Validation Audit Pilot: Lessons Learned, Results & Industry Reactions

May 23, 2017

Kim Browning, CHRS, PMP, CHC Executive Vice President

Jenni Monfils, CPC, CRC Risk Adjustment Compliance Coding Manager

Tom Nasadoski, MBA Manager, Risk Adjustment


Learning Objectives

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What do the results reveal?

What are likely changes/adaptions due to the results?

How is the industry reacting to these results?

What have Issuer’s and IVA entities learned?

What can you expect moving forward?


SVA results

o CMS is still in process of conducting SVA

o Results expected to be shared with Issuers and IVA entities in May or June (REGTAP 03/29/17)

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Results: Official


More work on Issuers and IVA entities than expected

Strong Claims Data Validation performance nationally

Weaker than expected performance with Demographic and Enrollment Validation

Technology changes o Replace Acumen tool

o Changes to or replacement of IVA Audit Matrix

CMS extension impacted multiple holidays

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Results: Industry


Medical records

o Acquisition more difficult than expected

o Supported newly found and non-EDGE claims varied dramatically across Issuers/IVA entities

o Importance of doing non-EDGE claims

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Results: Industry


CMS hosted two sessions for IVA entities

o Overall Meeting

• 01/25/17

o Medical Record Acquisition & Coding Meeting

• 02/15/17

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Lessons Learned: CMS Sponsored


Suggestions for improvement

o Issuer Documentation

o Provider awareness

o Package 1 and Package 2 submissions

o Protocol-related constraints

o State credentials have subsequently been eliminated for Benefit Year 2016

o Expediting medical record retrieval

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Lessons Learned: Overall Meeting


Lessons Learned: Medical Record Acquisition & Coding Meeting

Discussion topics o Medical records

• Mental health record challenges • Selection • Usable records • Matching to claims • Determining risk adjustment eligibility • Recommendations for improvement

Acquisition Ease of review

• Prioritization

o Approaches for non-EDGE claims and newly found HCCs

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Health Status Data Validation o Modifiers no longer required

• Including validation of screenshots for non-EDGE claims

o Inclusions for medical records • Progress notes

• History and physical

• Discharge summary

• Consultation reports

• Pathology reports

• Radiology (limited use)

• Medication list

Lessons Learned: REGTAP


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BY2016 Protocols released 05/16/17

Lessons Learned: IVA Protocols

o Demographic and Enrollment Validation • 50 member subsample

confirmed • Results not used in

error estimation

o Blind coding versus non-blind coding

o New IVA requirements for telehealth

o Crosswalks • Unique Enrollee ID needed

for full sample • Plan ID and Rating Area

only needed for subsample members

o Outstanding questions remain on Premium • Small group • Age • Tobacco


Lessons Learned: IVA Protocols

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o Error estimation, Phase I • Pair-wise test compares

SVA and IVA results • IVA results used and

extrapolated if differences are minimal

• SVA sample used with significant differences and IVA sample adjusted

o IVA sample adjustments,

Phase II • Alternate SVA sample used

to adjust IVA sample using one-for-one replacement

• Non-reviewed records adjusted based on SVA

o Error estimation • Stratum by stratum basis • Ratio estimator used to

extrapolate total score • Adjustment factor used to

issue plan risk scores

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About CDPHP

Not-for-profit health plan headquartered in Albany, N.Y.

Physician founded and directed

440,000+ members in 24 counties

Network model of approximately

5,000 physicians and

65+ hospitals

Offer HMO, PPO, EPO,

and high deductible products

Self-insured plans

Government programs, including

Medicare Advantage HMO and PPO,

Medicaid, Child Health Plus,

and Commercial Exchange

Confidential to CDPHP. Not for distribution without permission.

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What Do the Results Reveal? Everyone anxiously awaiting final results

What action can be taken based on results?

How will results impact strategy for the benefit year 2016 RADV?

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Reactions to Pilot

Tight deadlines

Increased scope of work

Claims Data Validation

Issuer documentation

Challenges with chart retrieval

Complex IVA Matrices

Results

When and what to expect

Anticipated changes going forward

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Lessons Learned Notify providers in advance of audit of what to expect

Create awareness among organizational leadership regarding scope of process and financial impact

Increase familiarity with Edge reports

RARSD

RACSS

RARSS

RADVDE

Importance of relationship with IVA

Mobilization of resources

Prioritization and timely submissions

Participation in REGTAP webinars

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What Are Likely Changes/Adaptions?

Efficiencies

Elimination of claim screen shots

Changes to the IVA Matrix

Scope of enrollment screen shots

Operational changes

More time to retrieve and review charts!!!!

Transition from Acumen to Salesforce

Improved communication

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Timeline

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What to Expect for Benefit Year 2016? Samples to be provided end of May

HCC level reporting

Medical record guidance

Full financial impact of results

More changes as results are disseminated

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Critical Success Factors in IVA Audit

People

Process

Technology

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Critical Success Factor: People

Relationships with physicians and their office staff Provider relations specialists

Contracting

TLC providers

Internal staff Awareness of cross functional roles and

responsibilities

Vendors IVA

Additional supporting

3rd parties

Top down organizational

support

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Critical Success Factor: Process

Plans must fully understand RADV and how to respond from a chart chase perspective:

Best practices to identify, pursue, collect, and review medical records in a short time frame

Coordination with IVA

Operational requirements established:

Internal vs. vendor responsibilities

Salesforce Audit Tool expectations

RADV readiness:

Conduct mock RADV audits

Ability to forecast potential liability

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Critical Success Factor: Technology

Integrate and manage the data via a database or spreadsheet infrastructure (relational database/ data warehouse/Excel)

Identify and select appropriate charts and locations

Generation of necessary data to provide optimal information for execution (reports, letters, talking points, CMS transmissions)

Establish data channels and file specs with vendor to transfer charts and receive coding data files

Proper access and knowledge of Salesforce system

Located in Minneapolis, Minnesota Independent, nonprofit health plan founded in 1984 Provide health coverage and services to Minnesota

residents 43,000 + provider network Product offerings

• State and Public Programs

• Special Needs Care • Medicare Advantage • Dual Plans

• Individual / Family Market – only on State Exchange

About UCare

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Lessons Learned: Overall

Review results from last years HHS-RADV • Prior to official results – review IVA results • Discuss with IVA any areas of concern

Review internal team • Adjust members • Set clear expectations for each role

Be prepared for additions or changes in the protocol Documentation is crucial Work with provider groups for chart retrieval Establish open communication with IVA

• Understanding of expectations and timelines

Create secure repository for all audit documents

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Understand data elements required for audit • How to reference EDGE reports

Work with correct internal stakeholders to understand and capture the flow of data from source system to EDGE Server • Review source data to

document any transference • Understand data calculations • Screenshots needed to

document all elements

Document all steps for each data element • Ask: Could a new employee

follow the process?

Include an example of each screenshot for reference

Communicate with IVA to verify clarity of documentation

Respond quickly with additional screenshots or references per preliminary findings by IVA

Lessons Learned: Documentation Mapping

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Reference mapping documentation for screenshot example

• Image integrity/clarity

• Image consistency

Set-up document files with required naming conventions

Determine process for screen capture—Snipping Tool, Paint, other

Document all steps including any redaction

Review all screenshots for accuracy and quality before submitting to IVA

Add notation for any unique situation

Best Practices: Screenshots

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Maintain list of medical record request contacts for provider groups

Understand contract language regarding record fees Pre-communication to provider groups

• Explain upcoming request and timing

Establish internal team resources for support - Who will be reaching out to providers to assist process?

Understand analytics for creating chart chase list Develop request process

• Including follow-up and tracking

Set-up files with required naming conventions Review chart prior to submission to IVA – is it complete,

legible, quality scan/copy, etc.

Lessons Learned: Chart Retrieval

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Documentation is never perfect

Request updates on a regular basis from IVA

Understand why a chart is not acceptable

Non-validating HCCs

• Analytics to find a supporting record

• Request additional charts

• Record issue

Prioritize gaps

Review results prior to submission

Lessons Learned: Health Status Data Validation

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Senior Official and Back-Up Senior Official

• Expectations

• Availability

Amount of time required to support audit

Look for education opportunities

• Internal data process

• EDGE submission

• Provider documentation

Document audit process

Understand IVA results prior to submission

Download and save copies of IVA and SVA documents

Lessons Learned: Miscellaneous

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Audit expectations for Benefit Year 2016

o Sample to be provided mid-end of May instead of July 1st

o RADVDE report will be corrected to reflect HCC level

o Audit components that will remain

• Enrollment and claims screenshots for NEC

• Majority of auditable data elements for Demographic and Enrollment Validation

Single month premium expressed as billed amount

• Newly found HCCs and non-EDGE claims

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Lessons Learned: Overall Meeting


Lessons Learned: RISE Nashville/REGTAP/Protocols

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Acumen tool replacement with new tool features

o Web forms

o Salesforce community

IVA Audit Matrix updates or replacement

Full sample for Demographic and Enrollment Validation reduced to subsample

o 50 members expected

Crosswalks

o Unique Enrollee ID/Masked ID required for all members

o Plan ID needed for subsample members

o Rating Area based on zip code

State credentials no longer required


Lessons Learned: RISE Nashville/REGTAP/Protocols

Medical records

o Specific data elements to be defined at later date

o CMS is exploring options to automate redacting within data results submission tool

• Chart thinning/reduction still expected

o CMS continues to work on mental and behavioral health record issues in states with stringent privacy laws

SVA for 2015 benefit year audit

o Underway; approximately 50% complete (as of 03/08/17)

o No additional insights shared at that time

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Lessons Learned: IVA Entity

Chart acquisition

o Encourage more provider education with Issuers

o Obtain key contacts and advise for large volume practices

o Expect chart fees

o Generic portal for providers to submit electronic medical records

Issuer Documentation

o Assessment and template introductions

o Strict adherence to due dates

o Pricing variations to accommodate varying degrees of support

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Lessons Learned: IVA Entity

Medical record review o 3:1 senior to junior coder

ratio

o Increased transparency of non-accepted medical records

o Enhanced redacting tool

o Increased reporting detail and frequency of medical record sharing (to complement Audit Matrix)

Audit Matrix o CMS making changes to

data results submission tool

o Align reports to reflect changes

o Continued review of data with Issuers in advance of submitting Audit Matrix to Issuer’s Senior Official

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Moving Forward

Expectations

o Issuers with < 500 member months exempt from participating in IVA but will get default error rate

• Lower of the national or state average negative error rates

o No second pilot year

o Tool de-bugging

o Post-Protocol changes via REGTAP

o Timeline shifts

o Accrual process for risk adjustment payment adjustments

o SVA appeals support

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For more information, please contact:

Q&A

Kim Browning, CHRS, PMP, CHC Executive Vice President [email protected]

Jenni Monfils, CPC, CRC Risk Adjustment Compliance Coding Manager [email protected]

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Tom Nasadoski, MBA Manager, Risk Adjustment [email protected]

mailto:[email protected]

Documents

Initial Validation Audit Pilot - cognisight.com · •Pair-wise test compares SVA and IVA results ... • Prior to official results – review IVA results • Discuss with IVA any