Session 9 PD, RADV Rating Factors. Moderator: Will Stabler

Transcription

1 Session 9 PD, RADV Rating Factors Moderator: Will Stabler Presenters: Sushma Jamboor, AHIMA, RHIT, MA, Commerial and RADV Specialist Marc David Lucas, ASA Eponine Lupo, Tessellate Principle Analyst SOA Antitrust Disclaimer SOA Presentation Disclaimer

2 2017 SOA Health Meeting Marc Lucas Session 9 Panel Discussion: RADV Rating Factors June 12, 2017

3 Basics of RADV Goal of the Medicare Advantage Audit is to identify any discrepancy by comparing Risk Adjustment Data diagnosis submitted by a Medicare Advantage Organization (MAO) via encounters and claims against the data provided to CMS per the RADV Audit Process CMS has three (3) primary objectives Verify enrollee CMS-HCCs Identify risk adjustment discrepancies Estimate the Part C national payment error rate Goal of the Commercial Audit is to balance payment within a state and within a market. The intent of the program is to calculate payments and charges at the plan level aggregated up to the issuer level. The Risk Adjustment under the Affordable Care Act (ACA) transfers funds from lower Risk Plans to higher Risk Plans the participants include non-grandfathered individual and small group market plans inside and outside of the Exchange. Overall goal is to mitigate potential adverse selection impact and premium stabilization in these markets.

4 Medicare Advantage RADV RADV Audit (Contract Level) Initiative is for a closed calendar year payment changes may occur based on error rate which will be extrapolated across the plan Random MA contracts health plans selected have 201 members from each plan Criteria CMS uses to target are: Problematic past data validation findings Plans with significant increase in risk scores Failure to comply with the requests for records in a National RADV audit A maximum of five medical records can be submitted in support of one targeted HCC Enrollee-level payment errors will be defined as the difference between the original payment and the RADVcorrected payment (per member per month). The payment error for each enrollee will be either positive (representing a net overpayment) or negative (representing a net underpayment). Health Plans can appeal CMS determinations CMS may impose penalty based on the audit findings

5 Medicare Advantage National Sample RADV National Sample Initiative is for a closed calendar year no payment changes or add/deletes in scope Random selection of MA members across all eligible MA contracts No limit to the number of medical record submissions per targeted HCC Full enrollee results are compared with the audited HCCs The difference between the original (RAPS) payment amounts and validated (RADV) payment amounts (including over and underpayments) is calculated for the National payment error rate and are reported to Congress Health Plans cannot appeal CMS determinations No financial penalty imposed CMS selects members randomly based on their risk factors, which in turn drives the MA plan chosen. Sample size depends on plan size

6 National Sample Experience

7 Commercial RADV HHS RADV Annual Audit on all on all issuers to ensure transfers among all issuers accurately reflect relative risk. 200 Enrollees per plan is selected as sample. HHS RADV validates both enrollment and medical claims data submitted to the Issuers External Data Gathering Environment. (EDGE SERVER) Six (6)Phases of HHS RADV Sample Selection Initial Validation Audit (IVA) Second Validation Audit (SVA) Error Estimation Appeals Payment Transfer Adjustment

8 Commercial RADV Continued HHS RADV PARTICPANTS

9 Commercial RADV Retrieval Rates Are Key Differentiator Sample of 25 plan results for

10 Potential Impact of Commercial RADV 2014 EDGE Data if you experienced less than favorable results on your data submissions Expect future audit on 2014 DATA Potential Impact on Premium (+/-) if Results Proportionately Impact PLRS for Risk Transfer

11 Comparing RADV

12 Who Had an MA RADV? 2007 RADV Pilot Average RAF * 2007 Star ratings were a % of possible stars on scale of 1 to 3 stars Recovery

13 Who Had an MA RADV? 2007 RADV Recovery

14 Who Had an MA RADV? 2011 RADV Average RAF

15 Who Had an MA RADV? 2012 RADV Average RAF 2012 RADV Average RAF

16 Doubling Down on RADVs (2 RADV)

17 Rating Factors: Risk Score Risk Scores seem unlikely to be associated with RADV selection

18 Rating Factors: Change in Average Risk Score

19 Rating Factors: Plan size

20 Rating Factors: Stars Potential bias to select 3.5 star plans 19

21 Rating Factor: Prior RADV Noting that Typically about 7% of plans have been selected for a RADV, but 15 of 92 RADVs were the second for as many plans, there may seem some potential for bias. Before drawing a conclusion, one should consider whether plans still fit into other rating factors Also notable: Every 2007 pilot had a RADV in 2011 (3) or 2012 (2) this would be 21 second RADV if you count pilots (which did result in recovery payments): 12 H contracts of thirty two 2007 RADVs had second audit (37.5%) Three 2011 H contracts also had 2012 RADVs Recovery Payment may also be a factor

22 Most Likely Targets (Based on 2011 & 2012 RADV Experience) Large Plans 3.5 star Change in Average Risk Adjustment Factor better than typical Had previous RADV?

23 Questions?

24 Thank You! Marc Lucas: Tessellate Vice President Risk Adjustment Reporting & Strategy, A.S.A Will Stabler: Tessellate Strategic Sales Executive Annette D Long: Tessellate Manager of Medicare Advantage Medical Record Retreival Sushma Jamboor: Tessellate Senior Analyst Contact: (804)