Medical Incentive Program

Transcription

1 Medical Incentive Program January 30 February 2, 2018 Palm Beach County Convention Center West Palm Beach, FL The Path to Data Excellence

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3 Medical Incentive Program Presented by: Jim Mallon and Lisa Ferguson Objectives MIP Learn the details of the Medical Incentive Program compliance criteria and how to monitor your reporting performance using the Medical Data Collection tool 2 1

4 Agenda 3 Medical Compliance Programs Overview 2

5 Compliance Programs Medical Incentive Program Quarterly Carrier Data Quality Report Program (Report Card) Medical Addendum Annual 5 Applicability All coverage provider groups are required to report the Medical Data Call in all NCCI states Independent bureau states are not subject to the Medical Incentive Program Alabama District of Columbia Iowa Mississippi New Mexico Tennessee Alaska Florida Kansas Missouri Oklahoma Texas Arizona Georgia Kentucky Montana Oregon Utah Arkansas Hawaii Louisiana Nebraska Rhode Island Vermont Colorado Idaho Maine Nevada South Carolina Virginia Connecticut Illinois Maryland New Hampshire South Dakota West Virginia 6 3

6 Evaluation Timing Evaluate each reporting group quarterly Data received as of due date Transaction Quarter Due Date Q1 June 30 Q2 September 30 Q3 December 31 Q4 March 31 Assessments are billed in the second month following the due date 7 Incentive Program Components 4

7 Compliance Objectives Full submissions by due date Medical Incentive Program Data meets or exceeds criteria Identify extreme outliers 9 Incentive Program Components Insufficient Data No data by the due date Completeness 5 categories submitted by due date Quality 19 elements with edits Each category within a component is judged pass/fail Refer to Data Quality Guidebook on ncci.com for details based on an individually determined threshold. 10 5

8 Incentive Program Components Insufficient Data No data by the due date Completeness 5 categories submitted by due date Quality 19 elements with edits Refer to Data Quality Guidebook on ncci.com for details 11 Incentive Program Results During the Due Quarter, the results displayed in the Medical Data Collection tool update as each file processes. Review results after the final submission for a quarter has processed Don t wait until the end of the Due Quarter Early review allows time to respond to issues. 12 6

9 Medical Data Collection Compliance results available in the Medical Data Collection tool: Quarter End Validation Incentive Program 13 Quarter End Validation 14 7

10 Quarter End Validation Displays Compliance Category Results All medical states NCCI compliance states Independent bureau states (individually by state) Fine Amounts Are Not Displayed 15 Texas Timeline Current Participants: Reporting started Q transactions Currently found with the independent bureau states Q transactions Due Q Incentive Q transactions TX New Participant Carriers: Q transactions Due Q Incentive Q transactions 16 8

11 Incentive Program 17 Incentive Program Displays Compliance Category Results NCCI compliance states only Fine Amounts Are Displayed Alabama Florida Kentucky Nebraska South Carolina Alaska Georgia Louisiana Nevada South Dakota Arizona Hawaii Maine New Hampshire Tennessee Arkansas Idaho Maryland New Mexico Utah Colorado Illinois Mississippi Oklahoma Vermont Connecticut Iowa Missouri Oregon Virginia District of Columbia Kansas Montana Rhode Island West Virginia 18 9

12 Incentive Results Screen Search Results by Reporting Quarter View the Highest Level of Results: Which components are failing? How much is the fine amount? 19 Incentive Program Assessment Categories 1 Insufficient Data 2 3 Completeness Quality 20 10

13 Insufficient Data Assessment Insufficient Data Assessment Completeness Assessment Quality Assessment 21 Submission Tracking Search Results by Reporting Quarter View the Status of Your Submissions Was the file submitted? Was the file processed or rejected? Were any records returned? 22 11

14 Completeness Components Calendar Year Paid Losses NCCI s minimum threshold is derived from NAIC Calendar Year (CY) Paid Losses Policy Year Paid Losses Losses for policies written in given year Accident Year Paid Losses Losses for accidents occurring in given year Calendar Year Paid Losses Transactions occurring in given year 24 12

15 Completeness Components State Coverage Provider Medical Data Provider Medical Service Service Date Distribution 25 State Verify that transactions are received for each expected state. Medical Paid Amount Approximately one transaction per $500 in medical paid Paid Loss At least $1,000,000 NAIC Paid Loss in the state Assumption Medical/ Indemnity split assumption: 55% Minimum transaction threshold is based on a group s NAIC CY Paid Loss in that state

16 Coverage Provider Verify that transactions are received for each expected coverage provider. Medical Paid Amount Approximately one transaction per $500 in medical paid Paid Loss At least $1,000,000 NAIC Paid Loss for a coverage provider Assumption Medical/ Indemnity split assumption: 55% Minimum transaction threshold is based on coverage provider s NAIC CY Paid Loss in all NCCI compliance states. 27 Medical Data Provider Verify that transactions are received for each expected medical data provider. Group Minimum of one transaction per quarter Minimum of one transaction per quarter Minimum of one transaction per quarter 28 14

17 Medical Service Verify that sufficient pharmacy data has been included in the quarterly data. Number of transactions with pharmacy place of service or pharmacyrelated provider taxonomy At least 4% of transactions Number of transactions reported for the quarter 29 Service Date Distribution The six most recent service months must have three consecutive months, each containing at least 12% of the transactions submitted for the quarter

18 Incentive Results Completeness 31 Completeness Results 32 16

19 Service Date Distribution Identifying the gap in service dates can reveal potentially missing transactions for August. 33 Trending Within a Category Comparing the count of Actual Transactions to the Threshold for each State or Coverage Provider can reveal a potentially missing file for a Coverage Provider

20 Research File Submissions 35 Research File Submissions 36 18

21 Quality Components Quality Evaluate quality by data element: Assessment Based on level of elements below tolerance 38 19

22 Critical Elements Elements necessary for a transaction to have value: Element Tolerance % Accident Date 95 Amount Charged by Provider 95 Jurisdiction State Code 95 Paid Amount 95 Service Dates Priority Elements Elements needed for legislative analysis: Element Tolerance % Network Service Code 95 Provider Identification Number 95 Provider Postal Zip Code 95 Quantity/Units per Procedure Code 95 Paid Procedure Code 90 Place of Service Code 80 Provider Taxonomy Code 80 Primary ICD Diagnostic Code 70 First Paid Procedure Code Modifier

23 Supplemental (Low) Elements Elements used in specialized studies: Element Tolerance % Second Paid Procedure Code Modifier 95 Birth Year 80 Claimant Gender Code 80 Secondary ICD Diagnostic Code 10 Secondary Procedure Code 0 41 Incentive Results Quality 42 21

24 Quality Results 43 Quality Results Click on Edit Sequence Number link to request a report

25 Quality Results Review Edit Extracts Request reports of failing reported values. Quarter End Validation Incentive Program Requested edit reports will be sent to your Data Transfer via the Internet (DTVI) mailbox. 45 Requests for Failing Values Delimited files provide information to help diagnose data quality issues. Edit Frequency Report Count of bill lines reporting invalid values Identifies which reported values failed the edit Edit Detail Extract Key details of bill lines reporting invalid values Allows investigation within source system 46 23

26 Recap Question A minimum threshold per state is established if Calendar Year Paid Losses are at least: Answer Which of the following is not an independent bureau state required to report medical data? 47 Assessment Calculation 24

27 Assessment Levels Assessment amounts are based on countrywide market share tiers: Assessment Level Market Share Range % 0.25% 2 > 0.25% 1.50% 3 > 1.50% 49 Volume Eligibility Statistical inferences are less reliable for low transaction volumes Transaction count < 2,500 Not fined for statistical fluctuations Applies to: Medical Service and Service Date Distribution Completeness categories All Quality data elements 50 25

28 Assessment Amounts Insufficient Data Based on the reporting group s market share. Market Share Insufficient Data Assessment Level Range Assessment % 0.25% $ 3,750 2 > 0.25% 1.50% $ 7,500 3 > 1.50% $15, Assessment Amounts Completeness Based on the reporting group s market share and the number of completeness categories that did not pass. Assessment Level Market Share Range Total Completeness Assessment Based on Categories Not Complete on Time % 0.25% $ 625 $1,250 $ 2,500 2 > 0.25% 1.50% $1,250 $2,500 $ 5,000 3 > 1.50% $2,500 $5,000 $10,

29 Assessment Amounts Quality Based on the reporting group s market share and the tolerance level (Low, Priority, or Critical) of the data element. Assessment Level Market Share Range Quality Assessment per Data Element Based on Tolerance Level Low Priority Critical % 0.25% $ 25 $125 $ > 0.25% 1.50% $ 50 $250 $ > 1.50% $100 $500 $1, Assessment Amounts Fine Multiplier Assessment amount increases for groups having multiple consecutive quarters with an assessment Escalation Factor Consecutive Quarters With an Assessment 54 27

30 1st Quarter Transactions Timeline Jan Feb Mar Apr May Jun Jul Aug Transactions Processed Data Submitted to NCCI Incentive Program Results Available Fine Billed End of Transaction Quarter Due Date/Incentive Results Finalized 55 Quarterly Schedule Example: Group NCCI Training Company Small sized regional carrier Provides coverage in FL and GA Two coverage providers in the group Each carrier is its own Medical Data Provider (MDP) Carrier/MDP reports monthly Carrier/MDP reports quarterly 56 28

31 Quarterly Schedule Example Jan Feb Mar Apr May Jun Jul Transactions Process MDP Submits Data MDP Submits Data Review Incentive Program Results Transaction Dates in 1st Qtr Submitting early allows more time to review and respond to issues before quarter end. Monthly Quarterly 1st Quarter Data Past Due Earlier is better 57 Carrier Data Quality Report Program (Report Card) Objectives Evaluates groups overall annual reporting performance Report Card Medical Addendum Pass or Fail Grade is based on Completeness/ Quality 58 29

32 Carrier Data Quality Report Medical Data Addendum 59 Report Card Example 1. Why does the 2015 Report Card start with Q transactions? 2. Does Q quality pass and why? 3. Does Q quality pass and why? 4. Is the overall grade for 2015 pass or fail and why? 60 30

33 Review and Appeals Review Process Implement corrective action Research the issue If you don t know your assigned validator, call 800 NCCI 123 or customer_service@ncci.com Contact your validator to discuss your results 62 31

34 Research the Issue Completeness Check Submission Tracking Implement Corrective Action Determine cause of issue: Did a submission reject? Did your Medical Data Provider(s) submit all of the data for the quarter? Did something change (e.g., new Bill Review Vendor)? Determine plan for issue resolution: Correction of issue in future submissions Possible correction of historical data Testing system changes 63 Research the Issue Quality Check Quality Results Implement Corrective Action Determine cause of issue: Did you or your Medical Data Provider(s) make a system change? Are there new tables (e.g., ICD 10, CMS)? Did something change (e.g., new Bill Review Vendor)? Determine plan for issue resolution: Correction of issue in future submissions Possible correction of historical data Testing system changes 64 32

35 Contact NCCI Contact your validator when the issue is with your system or processes. For these issues, your assigned validator may request additional information: Cause of the issue What will be corrected Outside Medical Data Provider/Bill Review Vendor/ Pharmacy Benefits Manager System change Likely requires submission of test file post change Historical data Future submissions only 65 Contact NCCI Contact your validator when the issue is not with your system or processes. For these issues, your assigned validator may request additional information: Completeness Quality Quarterly total medical paid losses Business exclusion(s) Details of any large losses being handled as a lump sum Detail of any losses outside the Medical Call reporting period Reference showing that edited values are valid industry standard codes Documentation of in house codes for review 66 33

36 Resources Resources ncci.com 68 34

37 Resources ncci.com 69 Resources ncci.com 70 35

38 Questions 71 36

39 Supplemental Information

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41 Presenter Biographies Jim Mallon has worked at NCCI for over 35 years in the Actuarial and Data Resources Divisions, and is currently in the Medical and DCI Operations Department. He is responsible for the validation of customers medical data and resolution of issues. Jim has a Bachelor of Science degree in mathematics from New York University Polytechnic Institute. Lisa Ferguson has worked at NCCI for more than 20 years and is a lead data analyst in the Medical Data Validation Department. Lisa has held several positions in Customer Operations and Data Resources, including customer service consultant, Unit data collection and validation analyst, operational lead of the Bureau Compliance Statistical Service and of New York Policy Services, residual market Pool data collection and validation analyst, and voluntary data services analyst. Lisa s current responsibilities include collecting, editing, storing, and validating data that is associated with NCCI s Medical Data Call. Lisa provides Medical Data Call systems support as well as data quality review.