Risk Adjustment User Group

Transcription

1 Risk Adjustment User Group May 15, :00 p.m. 4:00 p.m. ET

2 Agenda Purpose Policy Updates Guidance and Examples for MAOs and Other Entities Highlights and Reminders Upcoming Events and Resources Questions and Answers Closing Remarks Risk Adjustment User Group, May 15,

3 Purpose To provide Medicare Advantage Organizations (MAOs) and other entities with risk adjustment industry updates To offer guidance regarding risk adjustment policy and operations To provide reminders regarding submission requirements and resources Risk Adjustment User Group, May 15,

4 Target Audience The primary audience for this call includes: Medicare Advantage Organizations (MAOs) and Part D Plan (PDP) Sponsors Regional and Employer Group Health Plans Specialty Plans Medicare Medicaid Plans (MMPs) Programs for All Inclusive Care for the Elderly (PACE) Third Party Submitters Risk Adjustment User Group, May 15,

5 Policy Updates Risk Adjustment User Group, May 15,

6 Risk Assessment Code Beginning with 2014 dates of service, CMS instituted a new requirement for MA organizations and other entities to identify, in the diagnoses they submit to CMS, which diagnoses are from home visits. These data will enable CMS to evaluate how many diagnoses are identified in home visits. Risk Adjustment User Group, May 15,

7 Risk Assessment Code, continued Effective for dates of service (DOS) starting 1/1/2014, plans must populate the Risk Assessment field for all risk adjustment data submitted to RAPS. The Risk Assessment field must contain one of these values: A - Diagnosis code from a clinical setting B - Diagnosis code from a non-clinical setting originating in a visit that meets all requirements for First Annual Wellness Visit or Subsequent Annual Wellness Visit C - Diagnosis code from non-clinical setting originating in a visit that does not meet all requirements* for a First Annual Wellness Visit or Subsequent Annual Wellness Visit *For information on the requirements for a First Annual Wellness Visit and Subsequent Annual Wellness Visit, see 42 CFR (a). Risk Adjustment User Group, May 15,

8 Risk Assessment Code, continued Remember: For risk adjustment purposes, a setting is clinical or non-clinical based on the place of service (POS). (A setting is a POS, not a type of service or a type of provider.) For purposes of MA risk adjustment, a non-clinical setting is a beneficiary s home, which is referenced as code 12, Home, in the existing POS Codes for professional services located at: Use Risk Assessment code A for diagnoses that come from clinical settings. Use Risk Assessment codes B and C for diagnoses that come from non-clinical settings, that is, the beneficiary s home. Risk Adjustment User Group, May 15,

9 ICD-10 Code Transition Delayed On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No ) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, Risk Adjustment User Group, May 15,

10 Using EDS Diagnoses for Risk Score Calculation CMS will continue using diagnoses submitted to RAPS for 2015 risk scores calculations. Starting PY 2015 (DOS 2014), diagnoses for risk score calculation will also come from the Encounter Data System (EDS). Valid diagnoses from both RAPS and EDS will be used in equal measures with no weighting. Risk Adjustment User Group, May 15,

11 2015 Normalization Factors Model Normalization Code CMS-HCC model implemented in Clinically Revised CMS-HCC model implemented in CMS-HCC model for PACE plans ESRD Dialysis/Transplant model ESRD Functioning Graft model RxHCC model Risk Adjustment User Group, May 15,

12 Risk Score Review For Payment Year (PY) 2015, risk scores will continue to be calculated using two models, but will be weighted differently than in PY For PY 2014, risk scores from the 2013 CMS-HCC model are weighted by 25%, and risk scores from the 2014 CMS-HCC model are weighted by 75%. For PY 2015, risk scores from the 2013 CMS-HCC model will be weighted by 67%, and risk scores from the 2014 CMS-HCC model will be weighted by 33%. Risk Adjustment User Group, May 15,

13 Risk Score Calculation for PY 2015 Portion of risk score from 2013 model + Portion of risk score from 2014 model = Blended 2015 Risk Score Portion of risk score from 2013 model [(raw risk score from 2013 model) / (PY 2015 normalization factor for the 2013 model)] X (1 PY 2015 coding adjustment factor) X 67% = portion of the risk score from 2013 model Portion of risk score from 2014 model [(raw risk score from 2014 model) / (PY 2015 normalization factor for the 2014 model)] X (1 PY 2015 coding adjustment factor) X 33% = portion of the risk score from 2014 model Risk Adjustment User Group, May 15,

14 Risk Score Calculation PY 2015 Example Portion of the risk score from 2013 model 1. Raw RS = Demographic Factors + Diagnostic Coefficients Example raw RS = Normalized risk score = Raw RS /PY 2015 Normalization Factor for the 2013 model / = ; Rounded = MA coding adjusted risk score = Normalized Risk Score X (1 PY 2015 Coding Adjustment Factor) X ( ) = 1.099; Rounded = portion of the risk score = 2013 risk score X 67% X.67 = Portion of 2013 model risk score (rounded) = Risk Adjustment User Group, May 15,

15 Risk Score Calculation PY 2015 Example, continued Portion of the risk score from 2014 model 1. Raw RS= Demographic Factors + Diagnostic Coefficients Example raw RS = Normalized risk score = Raw RS /PY 2015 Normalization Factor for the 2014 model / = ; Rounded = MA coding adjusted risk score = Normalized Risk Score X (1 PY 2015 Coding Adjustment Factor) X ( ) = ; Rounded = portion of the risk score = 2014 risk score X 33% X.33 = Portion of the risk score from 2014 model = Risk Adjustment User Group, May 15,

16 EX: Risk Score Calculation PY 2015 Portion of the risk score from 2013 model + Portion of the risk score from 2014 model = Blended 2015 Risk Score 2013 portion of the RS portion of the RS Blended 2015 RS = Risk Adjustment User Group, May 15,

17 Guidance and Examples for MAOs and Other Entities Risk Adjustment User Group, May 15,

18 RAPS Error Codes After a file passes Front-End Risk Adjustment System (FERAS) checks, it moves to the Risk Adjustment Processing System (RAPS). RAPS edits the detail records for format, integrity, and validity. The edits may produce RAPS error codes. RAPS error codes notify plans of errors in the detail (CCC) level of the RAPS file, including errors in the diagnosis cluster. The levels that are edited for possible errors include: 300 level This level relates to the record. 400 level This level relates to the diagnosis cluster. 500 level This level s edits are informational. Risk Adjustment User Group, May 15,

19 RAPS Error Codes This table shows the level the errors affect, range of error codes, and definition and consequences of errors. Level Series Explanation of Errors and Consequences Record Record Cluster Record-level error - The record was bypassed and all editing was discontinued. No diagnosis clusters from this record were stored. Record-level error - All possible edits were performed, but no diagnosis clusters from this record were stored. Diagnosis cluster error - All possible diagnosis edits were performed, but the diagnosis cluster was not stored. Cluster Diagnosis delete error - Diagnosis was not deleted. Cluster Informational message - All edits were performed. Diagnosis cluster was stored unless some other error was noted. Location: CSSC > Risk Adjustment Processing System > Training> 2013 Risk Adjustment 101 Participant Guide Risk Adjustment User Group, May 15,

20 RAPS Error Codes Example Question submitted to the Risk Adjustment mailbox: Our plan received a 460 error on a RAPS file (Service From-and-Thru-date span is greater than 31 days). Does this error cause the entire record and file to be rejected, or only parts of the file? Risk Adjustment User Group, May 15,

21 RAPS Error Codes Example, continued Response: As seen in the RAPS Error Code Table, error code 460 is a diagnosis cluster error. This means that all possible diagnosis edits were performed, but the diagnosis cluster is not stored. Therefore, the other clusters in the record are not affected by this particular error. There are several tools plans can use to research error codes to determine descriptions. Risk Adjustment User Group, May 15,

22 RAPS Error Codes Research The RAPS Error Codes table is located on CSSC: CSSC > Risk Adjustment > Edits > RAPS Error Code Listing CSSC also has resources for researching RAPS Error Codes: The RAPS Error Codes table lists the description of each RAPS error code. (This table also contains the FERAS error codes.) Risk Adjustment User Group, May 15,

23 RAPS Error Codes Research, continued The RAPS Error Codes table is located on CSSC: CSSC > Risk Adjustment > Edits > RAPS-FERAS Error Code Lookup Plans can also use the RAPS- FERAS Error lookup tool. To use this feature: Enter the error code in the box. Click Search. The Search Results display the following elements: ocode odescription osuggestions Use the scroll bars to view all information. Risk Adjustment User Group, May 15,

24 Scores for Initial Year Model Run Versus Mid-year Model Run Question: Why are some risk scores higher on the initial year model run than they are on the mid-year model run? Answer: Risk scores can change from the initial to mid-year model runs because diagnoses for the initial model run have dates of service from the preceding July-June timeframe, whereas diagnoses for the mid-year model run is moved up six months, with dates of service from January to December of the preceding year. If an individual beneficiary s risk score decreases between runs, this could be due to a variety of factors. For example, the mid-year run does not capture a diagnosis that was used for the initial run or a Medicaid period no longer exists for the data period used in the mid-year model run. The example on the next three slides shows how risk scores can change from one payment month to another. The highlighted rows show the differences in the two risk scores. Risk Adjustment User Group, May 15,

25 Scores for Initial Year Model Run Versus Mid-year Model Run, Beneficiary Example LTI Status Risk Score Data January 2013 July 2013 Source MMR RAFT Code C C MMR Payment Year MMR Model PACE PACE MMR Payment Month January July MMR Normalization Factor Final Announcement Coding Adjustment Factor* Final Announcement Age/Sex Factor (Female 80-84) (Female 80-84) MMR Medicaid Factor MMR OREC Factor 0 0 MMR *The MA Coding Adjustment factor is applied to risk scores of MA and PACE enrollees for the following: CMS-HCC: community, institutional, new enrollee CMS-HCC ESRD: post-graft, post-graft new enrollee The MA Coding Adjustment factor is not applied to the following risk scores: CMS-HCC ESRD dialysis, dialysis new enrollee, transplants, and Part D. Risk Adjustment User Group, May 15,

26 Scores for Initial Year Model Run Versus Mid-year Model Run, Beneficiary Example, continued Risk Score Data January 2013 July 2013 Source Frailty Factor MMR Disease HCC: HCC019 (0.124) HCC019 (0.124) MOR Disease HCC: HCC079 (0.252) HCC085 (0.361) MOR Disease HCC: HCC085 (0.361) HCC0136 (0.227) MOR Disease HCC: HCC086 (0.283) Not applicable MOR Disease HCC: HCC096 (0.276) Not applicable MOR Disease HCC: HCC137 (0.227) Not application MOR Disease Interactions Disease Interactions INTI12 CHF_RENAL (0.201) INTI16_DIABETES_CHF (0.237) INTI12 CHF_RENAL (0.201) INTI16_DIABETES_CHF (0.237) MOR MOR Graft Factor (none) (none) MOR Risk Adjustment User Group, May 15,

27 Scores for Initial Year Model Run Versus Mid-year Model Run, Beneficiary Example, continued Risk Score Data January 2013 July 2013 Source Sum of Disease Coefficients Sum of Demographic/ Disease Factors MOR MOR MMR Normalized Score ALL w/ Coding Adjustment Factor ALL w/ Frailty MOR MMR Risk Adjustment User Group, May 15,

28 Scores for Initial Year Model Run Versus Mid-year Model Run, Beneficiary Example Differences The Part C risk scores were calculated using data from the MMR, MOR (demographic and diagnostic), and Final Announcement for the payment year to validate the scores on both the initial (dates of service 7/1/11 6/30/12, January Payment Month) and mid-year (dates of service 1/1/12-12/31/12, July Payment Month) risk scores. Note the difference in the number of diagnoses submitted between the two payment months. The diagnoses used in the mid-year run were not identical to the diagnoses used for the initial model run. These diagnoses were not included for the mid-year risk score, which is the July Payment Month. Risk Adjustment User Group, May 15,

29 Scores for Initial Year Model Run Versus Mid-year Model Run, Beneficiary Example Differences, continued RESULT: Risk score decreased from initial (dates of service 7/1/11 6/30/12, January Payment Month) to mid-year (dates of service 1/1/12-12/31/12, July Payment Month). Therefore, the plan will notice a decrease in payment due to the submission of fewer diagnoses. The plan should verify the diagnoses submitted for the midyear run. If appropriate, the plan should submit any missing diagnoses codes before the final reconciliation model run, which should change the risk scores and adjust the payment accordingly. Risk Adjustment User Group, May 15,

30 Diagnosis to HCC Mapping for Blended Risk Score Calculation For the blended risk score calculation, what happens when a diagnosis code maps to one model and not the other? Example: Diagnosis code is mapped to the 2014 CMS-HCC Model, but is not mapped to the 2013 CMS-HCC Model. Risk Adjustment User Group, May 15,

31 Diagnosis to HCC Mapping for Blended Risk Score Calculation, continued This affects the raw risk score part of the calculation: Remember - Portion of risk score from 2013 model for PY 2015 [(raw risk score from 2013 model) / (PY 2015 normalization factor for the 2013 model)] X (1 - PY 2015 coding adjustment factor) X 67% = portion of the risk score from 2013 model The raw risk score is calculated by adding the demographic factors to the diagnostic coefficients. In this example, diagnosis code does not match to an HCC for the 2013 model, so there is no coefficient for that diagnosis code for the 2013 raw score portion of the calculation. Diagnosis code does match to an HCC in the 2014 model, so there is a coefficient for that diagnosis code for the 2014 raw score portion of the calculation. Risk Adjustment User Group, May 15,

32 Highlights and Reminders Risk Adjustment User Group, May 15,

33 Production and Operations Schedule Reminders: MAOs must submit risk adjustment production data at least quarterly to CMS. Each quarterly submission should represent approximately ¼ of the data that an MAO will submit during a data collection year. Risk Adjustment User Group, May 15,

34 2014 Risk Score Reruns Reminder: Risk score reruns allow MA organizations to submit diagnosis deletions to the Risk Adjustment Processing System (RAPS). For the 2014 Risk score reruns, plans can only submit deletions to RAPS for the appropriate rerun payment years. The reruns affect MA Organizations, PACE Organizations, and certain Demonstrations. CMS will notify plans at least 30 days in advance of the deadline for submitting deletes for each data run. Send all questions about Risk score reruns to Risk Adjustment User Group, May 15,

35 2014 Risk Score Reruns, continued Reruns will be completed for the following prior payment years: Payment Year Dates of Service The first payment rerun for 2014 will be for PY All PY 2009 (2008 dates of service) deletions submitted to the Risk Adjustment Processing System (RAPS) through June 6, 2014 will be included in the risk score rerun. The sweep will occur as of June 6th. Risk Adjustment User Group, May 15,

36 Upcoming Events & Resources Risk Adjustment User Group, May 15,

37 Upcoming Events Risk Adjustment Webinar: June 19, 2014 Risk Adjustment User Group: September 11, 2014 To obtain information on upcoming events, visit the TARSC website and check the Upcoming Events box. Risk Adjustment User Group, May 15,

38 Resources Resource Centers for Medicare & Medicaid Services (CMS) CSSC Operations Technical Assistance Registration Service Center (TARSC) Risk Adjustment Mailbox Link Risk Adjustment User Group, May 15,

39 Resources, continued Resource ICD-10 Information ICD-10 Preliminary Mappings Link ICD10/index.html Plans/MedicareAdvtgSpecRateStats/Risk- Adjustors-Items/Prelim- IDC10Mappings.html?DLPage=1&DLSort= 0&DLSortDir=descending Risk Adjustment User Group, May 15,

40 Questions Risk Adjustment User Group, May 15,

41 Question #1 Q: Do PACE plans need to populate the MA Enrollee Risk Assessment Code? Risk Adjustment User Group, May 15,

42 Answer #1 A: Yes, the MA Enrollee Risk Assessment Code requirement applies to all entities that submit risk adjustment data to CMS, including PACE organizations. Risk Adjustment User Group, May 15,

43 Question #2 Q: If a member has had regular fee-for-service Medicare (both Part A & B) for four years, and they join a Medicare Advantage plan, will they come in as a New Enrollee or as a Full Risk beneficiary? Risk Adjustment User Group, May 15,

44 Answer #2 A: When moving from Medicare Fee-for-Service (FFS) into a Medicare Advantage Plan, the beneficiary you described will be full risk. In order to be paid under the full risk model, a beneficiary must have 12 months of Medicare Part B entitlement in a data collection year. Risk Adjustment User Group, May 15,

45 Question #3 Q: Our plan received the following RAPS Error for one of our beneficiaries: 460 SERVICE FROM-AND-THRU DATE SPAN IS GREATER THAN 31 DAYS. This beneficiary received physical therapy with the same diagnosis over a three (3) month period (90 days). How can we correct this error? Risk Adjustment User Group, May 15,

46 Answer #3 A: RAPS allows MA organizations to submit several occurrences of the same diagnosis in one cluster within a 31-day span*. The From date will reflect the first occurrence, and the Through date will reflect the final occurrence within the 31 days. If the From date and Through date span is greater than 31 days, the submitted data results in RAPS error code 460 SERVICE FROM AND THRU DATE SPAN IS GREATER THAN 31 DAYS. To avoid this error, split the occurrences into different clusters with date-span periods that do not exceed 31 days. *This rule does not apply to inpatient hospital data. Risk Adjustment User Group, May 15,

47 Answer #3, continued The plan should resubmit the occurrences as follows: Split these occurrences into at least three (3) diagnosis clusters for RAPS submission since this spans more than 31 days. Ensure that each diagnosis cluster does not exceed 31 days. Ensure that all diagnoses submitted are valid for the period being submitted, and the dates of service do not extend beyond the current month of the submission when splitting the claims. Risk Adjustment User Group, May 15,

48 Feedback Request Following this User Group, you will receive an requesting your feedback regarding this session. Please take a moment to respond to the questions and provide comments. This information will assist CMS with meeting your needs and enhancing your User Group participation experience. YOUR FEEDBACK IS IMPORTANT! Risk Adjustment User Group, May 15,

49 Closing Remarks Thank you for attending today s Risk Adjustment User Group session! We hope you will attend our next session. Risk Adjustment User Group, May 15,