Risk Adjustment Best Practices

Transcription

1 Sponsored By: Risk Adjustment Best Practices Tuesday March 14, 2017 (12:00 1:00 pm Pacific / 1:00 2:00 pm Mountain / 2:00 3:00 p.m. Central / 3:00 4:00 pm Eastern) Colleen Farrell, Managing Director Dr. David Koehler, Market Medical Director Michael Lee, Regional General Manger

2 Today s Presenters Colleen Farrell Managing Director Platform Strategy Michael Lee Regional General Manager Risk Adjustment David Koehler, MD Market Medical Director Deaconess Health System Colleen Farrell leads Evolent s Platform Strategy and Risk Adjustment team at Evolent. She has spent the majority of her career, including time at the Advisory Board Company and Salesforce, working with leading health systems and health plans to better leverage their data and technology systems to successfully manage risk and improve health care delivery in their markets. Mike Lee is a regional general manager and a co-founder of the Risk Adjustment business at Evolent Health. He oversees the delivery of risk adjustment capabilities and outcomes for health plan and health system clients nationwide. His prior operations experience includes leading Evolent s Health Plan Operations team, as well as delivering solutions at UnitedHealth Group and as a consultant with Booz & Company. Dr. David Koehler is Evolent s market medical director at Deaconess Health System. Dr. Koehler is responsible for leading change with physicians and other providers to improve the quality and efficiency of care in the Deaconess network. He provides clinical leadership and works to educate providers on high priority clinical initiatives, such as risk adjustment. He has been a physician leader and practicing family medicine physician at Deaconess for more than 20 years. 2

3 Topics Covered Risk Adjustment Overview A look at the process, populations and impact on your bottom line Common Myths The top five mistakes health plans and systems make in their risk adjustment programs Best Practices to Implement Now The strategies, tactics and tips to increase success in your program 3

4 Risk Adjustment Defined Risk Adjustment is a payment methodology used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee Risk adjustment is most relevant for health plans and health systems with delegated risk 4

5 Risk Adjustment Process Overview Prospective risk adjustment: Physicians must document a face-to-face encounter in the progress note during the year, and bill for the visit The diagnoses are submitted by the plan to CMS via a RAPS/EDPS files Retrospective risk adjustment: Health plans review prior year medical records to ensure accurately documented encounters were submitted for reimbursement Codes are submitted through a RAPS/EDPS file to CMS All codes must be backed by documentation Glossary: CMS (Centers for Medicare & Medicaid Services); RAPS (Risk Adjustment Payment System); EDPS (Encounter Data Processing System) 7

6 Risk Adjustment Population Variation Category Medicare (MA) Next Gen ACO ACA/Exchange Medicaid Avg Annual Premium $10,430 $10,430 $4,140 Varies by state RAF Score Defined a year in advance Defined a year in advance RAF defined in advance, Risk Pool Unknown Defined in advanced, Risk Pool Unknown Payment Structures Prospective & Retro Individual risk factor Re-start every year Prospective (No Retro) Aggregate or Population risk factor Prospective & Retro; Aggregate or Population risk factor Prospective; Aggregate or Population risk factor Score Timing Quarterly (Jan/Mar/Sept) Varies by state Annual due by April 30 Varies by state Funding Budget Plans bid assuming RAF of 1.0 paid based on that Potential to adjust ACO s final benchmark with cap of +/- 3% Zero sum game plans fund one another Typically, zero sum game / Budget neutral for state ROI Uncapped but typical ROI range 0-10:1 Capped at 3% Capped; ROI range TBD Capped and typically ROI range of 0-4:1 Membership ~ 18M ~1.35M ~20M ~60M Glossary: HCC Hierarchical Co-Existing Condition System ; CDHP Chronic Illness and Disability Payment System; CRG Clinical Risk Groups; Rx - Medicaid Pharmacy 8

7 Risk Adjustment Accuracy Impact* Condition Coded Score Actual Score 76 year-old female Medicaid eligible (Aged) Diabetes w/o complications (HCC 19) X Diabetes w/ complications (HCC 18) X Vascular disease (HCC 108) X Vascular disease w/ comp. (HCC 107) X CHF (HCC 85) X Total Risk Adjustment Score % IMPROVEMENT OVER CURRENT BID RATE *Illustrative example on Medicare Advantage member 9

8 Five Myths That Could Stop You From Achieving Your Financial Objectives The most common myths seen across some of the leading health plans and systems can be grouped into five major categories: Data and Analytics Retrospective Reviews Physician Workflow Compliance Operational Oversight 10

9 Myth #1 Data and Analytics Your EMR s problem list is the best source for risk adjustable conditions MYTH REALITY 11

10 Best Practices Data and Analytics Don t expect the problem list to be the most accurate source for risk adjustment opportunities Claims data is a more reliable source of truth Invest in an analytics tool that informs your problem list based on multiple sources 12

11 Myth #2 Retrospective Reviews Retrospective chart reviews are sufficient for risk adjustment MYTH REALITY 13

12 Best Practices Retrospective Reviews Retrospective chart reviews tend to be largely a revenue cycle activity Invest in prospective risk adjustment for the long-term Exposes the physician to additional diagnoses that a patient may have Increases the clinical insight and informs other activities like care management Drives more complete and accurate documentation 14

13 Myth #3 Physician Workflow One size workflow fits all MYTH REALITY 15

14 Best Practices Physician Workflow Have more than one way to view and attest suspect conditions in place to support a diverse physician network Develop and sustain a rigorous communication and training program 16

15 Spotlight Engaging Physicians Multi-modal delivery of risk adjustment opportunities across physician network >> PAPER CLOUD-BASED WORKFLOW EMR INTEGRATION Concierge service for delivery and retrieval of risk adjustment forms Cloud-based workflow that automates risk adjustment processes, can be integrated to native EMR Custom risk adjustment process embedded in the native EMR Bringing risk adjustment insights to your physicians at the point-of-care >> CENTRALIZED ANALYTICS PRIORITIZED WORKFLOW DATA-DRIVEN DIALOGUE HCC Code HCC Code HCC Code Eliminates double documentation and false signals Increases practice efficiency, optimizes physician time Enhances quality of patient-physician encounter 17

16 Myth #4 Compliance Risk adjustment: Set it and forget it? MYTH REALITY 18

17 Best Practices Compliance Proactively invest in software and infrastructure to ensure compliance and reduce errors Conduct mapping exercises to help identify where gaps may occur Enable governance checks and balances Hold mock RADV audits 19

18 Spotlight The Swoben Case Case alleged that insurers infrastructure was a one-way coding process that skewed the Medicare Advantage data reported to CMS An appeals court stated that CMS has always required insurers have an obligation to undertake due diligence to ensure the accuracy, completeness and truthfulness of the encounter data submitted Swoben was involved in a prior case that resulted in a $320M settlement between the state and his former employer 20

19 Myth #5 Operational Oversight Technology is the answer to solve risk adjustment MYTH REALITY 21

20 Best Practices Operational Oversight Pair technology with accountable operations Experienced staff to manage tactics, mitigate risk and deliver results Continuous improvement that enables year-overyear process efficiencies 22

21 Spotlight Next Gen ACOs MONITORED KEY PERFORMANCE INDICATORS STREAMLINED PROVIDER WORKLOAD Number of outstanding dx Number of HCCs verified by claims Percentage of population with Annual Wellness Visits (AWV) Number of high priority patients seen for AWV HCC re-documentation rate Outstanding chronic HCCs Projected RA score Percentage of providers with RA training 21

22 Final Thoughts Risk adjustment is a critical component of your value-based clinical and financial strategy There is no silver bullet to risk adjustment Keep compliance top of mind Technology by itself is not enough, invest in experienced staff, education and communication 24

23 Questions? +connect Colleen Farrell Michael Lee David Koehler 26

24 To Complete the Program Evaluation The URL below will take you to HFMA on-line evaluation form. You will need to enter your member I.D. # (can be found in your confirmation when you registered) Enter this Meeting Code: 17AT12 URL: Your comments are very important and enables us to bring you the highest quality programs! 27