Welcome to Blue Cross Commercial Risk Adjustment Webinar

Transcription

1 Welcome to Blue Cross Commercial Risk Adjustment Webinar For the listening benefit of webinar attendees, we have muted all lines and will be starting our presentation shortly This helps prevent background noise (e.g. unmuted phones or phones put on hold) during the webinar This also means we are unable to hear you during the webinar Please submit your questions directly through the webinar platform only How to submit questions: Open the chat feature at the top of your screen to type your question related to today s training webinar In the Send to field, select Webinar Host Once your question is typed in, hit the Send button to send it to the presenter We will address submitted questions at the end of the webinar 1

2 Commercial Risk Adjustment Webinar August 30, 2016 Presented by Pat O Gwynn Provider Relations Department Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company. 2

3 What is Commercial Risk Adjustment (CRA)? Risk adjustment, which is not a new concept, is a method using patient claims data to predict health care costs based on the relative risk of enrollees. Commercial Risk Adjustment (CRA) is one of three premium stabilization programs established by the Affordable Care Act under the market reforms beginning in The overall goal of CRA is to provide certainty and protection against adverse selection in the individual and small group markets while stabilizing premiums. Before January 1, 2014 After January 1, 2014 Health plans calculated risk through their own underwriting process to determine if a person was eligible for coverage. Healthcare is guaranteeissued to all consumers. 3

4 Who Does CRA Apply to? CRA applies to our members with non grandfathered individual and small group benefit plans sold on and off the marketplace. Does not apply to BlueCard (out of area) and Federal Employee Program (FEP) members. 4

5 Gathering GAPS Data Blue Cross uses claims data to identify members with potential documentation coding gaps (GAPS). Data gathering period is January 1 through December 31 of each year. Risk scores are recalculated every calendar year, therefore diagnosis codes must be documented at each visit for all conditions treated or taken into consideration by a provider. When an active diagnosis is not documented, GAPS occur. 5

6 Risk Loss Sources Suspected GAPS are identified through the following risk loss sources: History: Claims data is pulled from prior years and compared to claims data in the current year to identify chronic conditions not coded in the current year on a risk eligible claim. Pharmacy: Prior and current year pharmacy claims are evaluated for drugs that may signify a particular condition not coded in the current year on a risk eligible claim. Diagnostic: Prior and current year lab or diagnostic tests are evaluated for tests generally performed for a specific condition not coded in the current year on a risk eligible claim. Other: Prior and current year claims with diagnoses that signify a potential coexisting condition not coded in the current year on a risk eligible claim. 6

7 Whose Patient is This? BCBSLA CRA Reports use two models of attribution to identify who the patient belongs to: Standard Attribution: The member is attributed based on provider selection, member selection or the physician the member saw the most. Usually aprimary care provider (PCP) May be assigned to a specialist when no PCP meets the standard attribution criteria Enhanced Attribution: The member is attributed to a specialist based on member GAPS and the probability that a certain provider specialty will document a particular condition. A member may display on Risk Member Gaps Reports more than once under different providers because two models are used. 7

8 How a Risk Score is Calculated Individual risk scores are calculated based on an individual s age, sex and diagnosis. Diagnosis codes map to HCC s (hierarchical condition categories) which are organized into body systems or similar disease processes. HCC s are used to calculate the risk score. The sicker the patient, the higher the risk score. Blue Cross then sends risk score related information to CMS. This is why it is so critical that the claims we receive from our providers reflect the total risk profile of each patient. 8

9 Why Proper Coding Matters Patients receive increased quality of care. Improves identification of members into disease management programs Improves identification of care gaps for preventative care of chronic conditions and outreach programs Providers are able to achieve appropriate reimbursement or payments through more accurate coding practices. Providers can minimize the administrative burden of paperwork through complete and accurate coding practices. (i.e. Fewer requests for Medical Records and audits) 9

10 Proper Coding Accuracy and specificity in diagnosis coding and medical documentation are critical in risk adjustment models. Risk adjustment coding is all about painting the most accurate, clinical picture of your patient. Document up to 12 diagnosis codes per CMS 1500 claim form. Document up to 26 diagnosis codes per UB 04 claim form. Specific diagnosis codes must be documented by the treating, licensed provider for face toface visits. Documentation must be signed, credentialed and dated by the treating provider, otherwise, it is not acceptable by Blue Cross standards. 10

11 Proper Documentation To ensure proper coding, healthcare provider must document to the highest level of specificity (example: using the MEAT protocol): Monitor the condition Evaluate the condition Assess the condition Treat the condition Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes may be used as secondary codes, if the historical condition or family history has an impact on current care or influences treatment. 11

12 Proper Documentation Diagnose all conditions that are used in the provider s medical decision making for the visit or encounter. Diagnose to the greatest level of specificity. Chronic and/or co existing conditions should be documented and submitted on the claim. Do not use symbols or slang. The name on the record and other documents must match. Each page of the chart must list the patients name, DOB and date of service. Notes and signatures must be legible and on each chart entry with physician name, title and date. If it isn t documented, it hasn t been done is an adage frequently heard. For every service billed, you must indicate the specific sign, symptom or patient complaint that makes the service reasonable and necessary. 12

13 Examples of Proper Documentation Addressing all present conditions and the status (example: STABLE continue meds, etc.) If member has diabetes, does the provider consider it before treating another condition? It needs to be in a statement (example: well controlled on insulin or Diabetes stable, etc.) Chronic conditions must be documented and coded as chronic (example: hepatitis, renal insufficiency, bronchitis, etc.) Chronic conditions or status codes must be documented in the medical record at least once per year (example: transplant status, amputation status and paraplegia) 13

14 Examples of Proper Documentation Incorrect Documentation H/O CHF, meds Lasix Correct Documentation Compensated CHF, stable on Lasix H/O angina, meds nitroquick Angina, stable on nitro H/O COPD, meds Advair COPD controlled w/advair Note: There is an exception. It is appropriate to document/code (H/O) when documenting some status conditions; (e.g. Amputation, Transplants, Paraplegia). 14

15 Implications of Coding Errors Did you know that the estimated cost for a provider to resubmit an adjusted or corrected claim ranges on average from $15 to $25 per claim? The journey of just one claim that must be resubmitted includes the initial claim being received. Processing claims includes edits and retrospective reviews checking for potential errors. Upon discovery of an error, the claim is returned or denied for a corrected claim. The provider must then resubmit a corrected claim to begin the process again. Just 100 claim resubmissions could result in a loss of $1500. Accurate medical records and diagnosis codes captured on claims help reduce the administrative burden of medical record requests and adjusting claims for both the provider s office and healthcare insurers. Proper documentation and coding = the total risk profile of each member. 15

16 Unacceptable Diagnosis Codes Only valid diagnosis codes may be abstracted for risk scoring purposes. Examples of unacceptable diagnosis include: Rule out (R/O) Possible Probable Provisional Suspected Be accurate. Be specific. Be thorough. Be consistent. 16

17 Best Practices for Coding When coding wellness visits, include all diagnosis that coexist on the claim, the claims will apply the benefit correctly as long as you have the wellness code as the primary diagnosis. If the member has not been seen for the year, the provider should see the member for an annual well visit, then document and submit the claim for all existing conditions. NOT just the V code for a well visit (benefits will be applied appropriately). Blue Cross cannot assume the most specific code. 17

18 Best Practices for Documentation Use these words: DUE TO. Use them a lot. Neuropathy DUE TO diabetes Neuropathy DUE TO alcoholism There is almost no documentation that isn t improved by adding DUE TO after (almost) every diagnosis. Document CHRONIC or ACUTE correctly. BE SPECIFIC. Make a note when you review and update medication lists. Ask yourself: Can I be more specific? Think in ink. Warning: if the physician does not write it down, it cannot be coded. Codes are not documentation! Use words. 18

19 Member Gaps Report The Member Gaps Report is a new tool in ilinkblue. It is available to Quality Blue providers only at this time. The Member Gaps Report provides information on members with suspected documentation coding gaps (GAPS) for Commercial Risk Adjustment. Providers should review this report at least quarterly to evaluate their attributed patients suspected GAPS to determine patients in need of outreach efforts. Providers should complete the following actions related to this report: If a patient has not had a recent visit, contact the patient to setup an evaluation. From that visit, the provider should submit a claim with all valid diagnoses. If the patient had a recent visit with the provider, review the chart to ensure all valid diagnoses were submitted to Blue Cross. Any missing diagnoses identified should be submitted to Blue Cross on a corrected claim. 19

20 Accessing the Member Gaps Report 1. Log on to ilinkblue Click the Member Gaps menu. 20

21 Accessing the Member Gaps Report 3. This opens the Member Gaps Summary Report landing page. Choose your provider based on NPI, Provider Name and Specialty. Click the Submit button Doe, John-Internal Medicine Doe, Jane-Family Practice 21

22 Accessing the Member Gaps Report 4. Once you select a provider, the Member Gaps Summary Report will appear. This report provides a listing of your Blue patients with suspected documentation coding gaps. To view the Member Gaps Detail Report of an individual patient, click the appropriate hyperlinked Member ID. 5. Click the Printable View button to print the summary listing in a printer friendly view. 22

23 Member Gaps Detail Report 6. When you click on the link for an individual patient, it allows you to view and print the Member Gaps Detail Report for the selected patient. Click the Print button to print. 23

24 What is in the Member Gaps Detail Report? 1. Member: Member ID 2. Member Name: Member Name 3. Member DOB: Member Date of Birth 4. Provider ID: BCBSLA ilinkblue Provider ID 5. Attributed Provider: Attributed provider name with BCBSLA Claims System Provider ID. 6. Member Seen by Attributed Provider in the Current Year: Yes/No flag indicating whether or not the member saw the attributed provider in the current year. 7. Last Date Seen by the Attributed Provider in the Current Year: Date field displaying the last date the member saw the attributed provider in the current year. If the member did not have a current year visit then N/A will be displayed. 8. Risk Loss Source: Suspected GAPS source history, pharmacy, diagnostic or other. 9. Diagnosis Code: Diagnosis code that was identified from the Risk Loss Source other than Pharmacy. 10. Diagnosis Description: Diagnosis description associated with the diagnosis code. 11. Pharmacy Drug Name: Pharmacy drug name prescribed for the member when the Risk Loss Source equals Pharmacy. 12. Last Coded: Last date the diagnosis was coded or the pharmacy drug was filled. 24

25 RADV Audit The purpose of the Risk Adjustment Data Validation (RADV) audit is to ensure the accuracy of enrollment, claim and diagnoses data sent to CMS for CRA. One of the requirements set forth by the Affordable Care Act is that health plans, including Blue Cross and Blue Shield of Louisiana, must submit a valid sample of risk scores to the Centers for Medicare and Medicaid Services (CMS) for review. To meet this requirement, Blue Cross must contract with an independent Initial Validation Auditor. We have chosen to partner with Examination Management Services, Inc. (EMSI). 25

26 RADV Audit The HHS RADV audit process began this summer. On behalf of Blue Cross, please assist EMSI with their medical record requests for our members. For the scope of this audit, Blue Cross will require medical records for dates of service between January and December of

27 Medical Records at No Cost Reminder Per your Blue Cross provider agreement, you are not to charge a fee for providing medical records to us or agencies acting on our behalf. Please be sure to inform your staff and copy centers the request is for a BCBS Audit. 27

28 Additional Resources For additional information on CRA, view our HCR News. It is available online at then click on News. You may also contact you Provider Relations Representative. To find your representative, use our Provider Representative Map. It is available online at then, click on Provider Tools. 28

29 CME Credits We offer network providers CME credits directly through the Washington University CME Portal 29

30 ADDRESSING YOUR At this time, we will address the questions you submitted electronically through the webinar platform. 30