Medicare Advantage is one of the few areas your clinic can generate risk scores. Learn the basics of the program, strategies to increase your reimbursement processes to monitor compliance with 5 star and tools available on the market to help your physicians.
1. Medicare
 Advantage
Â
Wednesday,
 March
 26,
 2014
Â
Disclaimer:
 Nothing
 that
 we
 are
 sharing
 is
 intended
 as
 legally
 binding
 or
 prescrip7ve
 advice.
 This
 presenta7on
 is
 a
Â
synthesis
 of
 publically
 available
 informa7on
 and
 best
 prac7ces.
Â
2. â˘âŻ Originated
 with
 the
 Balance
 Budget
 of
 1997
Â
â⯠Addi7on
 to
 Part
 A
 &
 B
Â
â˘âŻ Part
 A
 â
 Hospitals
Â
â˘âŻ Part
 B
 â
 Professional
Â
Â
â˘âŻ Part
 C
 â
 Medicare
 Advantage
 (MA)
Â
â⯠Certain
 age
Â
â⯠Disabled
Â
â⯠Sign
 over
 beneďŹts
 to
 a
 private
 HMO
Â
â⯠Special
 Needs
 Plan
 for
 pa7ents
 with
 terminal
 illness
 (e.g.
 End-Ââ
stage
 renal
 disease)
Â
Â
â⯠Eligibility
Â
â˘âŻ Part
 D
 â
 Medica7ons
Â
Medicare
Â
3. Reimbursement
 Model
Â
â˘âŻ Provided
 by
 an
 index
 per
 county
Â
Â
â˘âŻ Plan
 bids
 to
 CMS
 every
 June
Â
ââŻProposed
 capita7on
 per
 member
Â
ââŻPlan
 beneďŹts
Â
ââŻConďŹden7al
Â
â˘âŻ New
 packages
 announced
 in
 October
Â
â˘âŻ Plan
 eďŹec7ve
 January
 1
Â
â˘âŻ 5-ÂâStar
 Plans
 get
 beSer
 enrollment
 beneďŹts
Â
4. Reimbursement
 Example
Â
â˘âŻ Bid
 for
 $500
Â
â˘âŻ Miami-ÂâDade
 County
 index
 ra7ng
 $900
Â
â˘âŻ Balance
 split
 between
 plan
 and
 Medicare
Â
â⯠Add
 $200
Â
â˘âŻ Bonus
 based
 on
 star
 ra7ng
Â
â⯠Add
 $100
Â
â˘âŻ Factor
 in
 Risk
 score
Â
â⯠Mul7ply
 by
 risk
 factor,
 e.g.
 2
Â
â˘âŻ Reimbursement
 calcula7on:
Â
500
 +
 200
 +100
 =
 800
 *
 2
 =
 $1600
 is
 reimbursed
Â
5. Hierarchy
 Condi7on
 Categories
 (HCC)
Â
â˘âŻ Risk
 Adjustment
 Factor.
Â
â˘âŻ Risk
 Adjust
 Process
 System
 ďŹle
 (RAPS).
Â
â˘âŻ HCC
 must
 be
 assessed
 once
 during
 a
 calendar
 year
Â
â⯠Assessment
 must
 have
 a
 corresponding
 plan
 of
 care
 within
 the
Â
physician
 note
Â
â˘âŻ HCC
 codes
 must
 be
 capture
 in
 the
 pa7ent
 chart
Â
â⯠Clinical
 Document
 Improvement
 Specialist
Â
Â
â⯠Coders
Â
â˘âŻ 8
 diagnosis
 codes
 allowed
 under
 4010
 and
 12
 diagnosis
 under
 5010
Â
â˘âŻ NextGen
 8.3
 templates
 have
 unlimited
 Diagnosis
 codes
 capability
 with
Â
ICD-Ââ10
Â
â˘âŻ Ability
 to
 have
 claim-Ââsplidng
 to
 submit
 more
 diagnosis
 codes
 if
 needed
Â
6. HCC
 Code
 Management
 and
 Recer7ďŹca7on
Â
â˘âŻ Integrated
 IMO
 search
Â
Â
ââŻHCC
 codes
Â
Â
ââŻRxHCC
 code
Â
Â
ââŻCorresponding
 Risk
 Adjustment
 Factor
 and
 prompt
Â
for
 a
 second
 code
 if
 needed
 to
 submit
 diagnosis
Â
Â
â˘âŻ Flag
 for
 codes
 not
 recer7ďŹed
 in
 preceding
 year
Â
7. â â â â â Ra7ng
Â
â˘âŻ Plans
 rated
 on
 1
 to
 5
Â
â˘âŻ Five
 star
 ra7ng
 system
 created
 by
 CMS
Â
Â
â˘âŻ Ra7ng
 system
 components
 announced
 in
 June
Â
â˘âŻ Tangible
 beneďŹts
 to
 increasing
 star
 ra7ngs:
Â
ââŻBonus
 for
 plans
 who
 achieve
 a
 4
 or
 5
 stars
Â
ââŻOnly
 5
 star
 plans
 can
 market
 and
 accept
 new
Â
members
 year
 around
Â
â˘âŻ Plans
 with
 historical
 low
 star
 ra7ng
 may
 be
Â
removed
Â
8. Monitoring
 Systems
 -Ââ
 HEDIS
Â
â˘âŻ Healthcare
 EďŹec7veness
 Data
 and
 Informa7on
Â
Set
 (HEDIS)
Â
â⯠Used
 by
 more
 than
 90
 percent
 of
 health
 plans
Â
â⯠Measures
 performance
 on
 important
 dimensions
 of
Â
care
 and
 service
Â
â˘âŻ HEDIS
 Requirements
Â
ââŻRequired
 protocols
 built
 directly
 into
 the
 Disease
Â
Management
 tab
Â
ââŻAlerts
 when
 pa7ents
 are
 overdue
 for
 required
Â
tests
Â
9. Monitoring
 Systems
 -Ââ
 CAHPS
Â
â˘âŻ Consumer
 Assessment
 of
 Healthcare
 Provider
 and
Â
Systems
 (CAHPS)
Â
â⯠Survey
 to
 determine
 which
 services
 were
 oďŹered
 to
Â
members
 by
 their
 plan
Â
â˘âŻ Health
 Outcome
 Survey
 (HOS)
Â
Â
â⯠Survey
 to
 measure
 pa7ent
 percep7on
 of
 plan
 eďŹec7veness
Â
â˘âŻ CAHPS
 and
 HOS
 Flags
Â
â⯠Cannot
 be
 inďŹuenced
 directly
 though
 the
 EHR
Â
â⯠Flags
 can
 be
 placed
 in
 the
 EHR
 for
 CAHPS
 or
 HOS
 survey
Â
â˘âŻ Alert
 shown
 each
 7me
 the
 pa7ent
 is
 seen
 or
 to
 help
 ensure
 that
Â
the
 survey
 is
 returned.
 Reports
 can
 be
 run
 against
 these
 alerts
Â
10. Monitoring
 Systems
 -Ââ
 Medica7ons
Â
â˘âŻ Medica7ons
Â
â⯠Compliance
 required
 to
 ensure
 pa7ent
 health
 is
Â
monitored
Â
â⯠High
 Risk
 Medica7ons
 that
 a
 pa7ent
 is
 taking
Â
â˘âŻ Complica7ons
Â
â⯠Controlling
 medica7ons
 dispensing
 impera7ve
 to
 5
Â
star
 ra7ng,
Â
Â
â˘âŻ Leveraging
 EHR
Â
â⯠Clinical
 Guidelines
 por7on
 of
 Disease
 Management
Â
suggest
 medica7on
 based
 on
 disease
 protocols
Â
â⯠Formulary
 checking
 func7onality
Â
11. Meaningful
 Use
 (MU)
Â
â˘âŻ Eligible
 Professionals
Â
ââŻ80%
 of
 services
 to
 members
 of
 a
 single
 plan
Â
Â
ââŻMU
 requirements
 for
 MA
 same
 as
 Part
 B
Â
providers.
Â
Â
â˘âŻ Do
 not
 need
 to
 submit
 on
 Clinical
 Quality
Â
Measure
 (CQM)
Â
Â
â˘âŻ Reimbursements
 paid
 directly
 to
 the
 plan
Â
â˘âŻ SpeciďŹc
 requirements
 and
 dates
 for
Â
registra7on
 and
 aSesta7on
Â
12. Provider
 Models
Â
â˘âŻ Contract
 with
 provider
 networks
 for
 delivery
Â
of
 care
Â
â˘âŻ Provider
 model
 can
 either
 be:
Â
ââŻStaďŹ
Â
Â
ââŻIPA
Â
14. The
 Partnership
Â
â˘âŻ Leon
 Medical
 Center
 in
 Florida
Â
ââŻFaced
 with
 ul7matum
Â
â˘âŻBring
 organiza7on
 live
 on
 NextGen
 in
Â
6
 months
 for
 $1
 million
 or
 lose
 MA
Â
contract
Â
â˘âŻ Team
 approach
 to
 op7mizing
 Medicare
Â
Advantage
 system
 and
 procedures
Â
15. The
 Turnaround
Â
â˘âŻ Reshaped
 organiza7on
 by
 focusing
 on
 3
 priori7es:
Â
â⯠Maintain
 accurate
 Risk
 Score
 for
 each
 pa7ent
Â
â⯠Improve
 the
 quality
 ra7ng
Â
Â
â˘âŻ Health
 Screening
Â
â˘âŻ Chronic
 Condi7ons
Â
â˘âŻ Consumer
 sa7sfac7on
Â
â⯠Control
 Costs
 through
 u7liza7on
 management
Â
â˘âŻ Implementa7on
 strategy:
Â
â⯠Build
 a
 strong
 team
Â
â⯠Ensure
 providers
 comply
 with
 coding
 guidelines
Â
â⯠Establish
 workďŹows
 that
 support
 quality
 improvements
Â
â⯠Implement
 technology
 that
 supports
 established
 standards
 and
Â
procedures
Â
16. The
 Accomplishment
Â
â˘âŻ Leon
 Medical
 Center
 upgraded
 the
 system
 in
 2
Â
months
 to
 create
 a
 live
 produc7on
Â
environment
Â
â˘âŻ Brought
 live
 100
 physicians
 in
 7
 loca7on
 in
 4
Â
months
Â
â˘âŻ Tracked
 progression
 via
 go-Ââlive
 scorecard
Â
aligned
 with
 goals
Â
17. The
 Results
Â
â˘âŻ With
 the
 $1
 million
 investment:
Â
ââŻQualiďŹca7ons
 of
 all
 primary
 care
 physicians
 for
Â
Meaningful
 Use
 program
Â
â˘âŻ $2
 million
 in
 reimbursements
 from
 CMS
Â
ââŻA
 .2%
 increase
 in
 the
 organiza7ons
 CMS
 Risk
Â
Adjustment
 Factor
Â
ââŻAwarded
 5-ÂâStar
 ra7ng
 by
 CMS
Â
â˘âŻ Per-Ââcapita
 bonus
 that
 is
 rolled
 back
 into
 the
 clinical
Â
service
 for
 members
Â
â˘âŻ Year-Ââround
 member
 enrollment
Â
19. Medicare
 Advantage
 in
 NextGen
Â
â˘âŻ HCC
 Code
 check
Â
â˘âŻ Applica7on
 ConďŹgura7on
Â
Â
ââŻEnable
 HCC
 in
 Prac7ce
 Preferences.
Â
ââŻEHR
 Master
 Files
 â
Â
Â
â˘âŻ System
 !
 Prac7ce
 !
 Prac7ce
 Preferences
 !
 Charge
Â
Entry
 !
 DiďŹeren7ate
 Risk
 Adjust
 Diagnosis
Â
â˘âŻ âEnable
 HCC
 for
 this
 pa7entâ
 checkbox
 on
Â
*Intake
Â
ââŻMakes
 HCC
 buSon
 visible
Â
21. Medicare
 Advantage
 in
 NextGen
Â
â˘âŻ Medicare
 Advantage
 one
 of
 the
 most
 lucra7ve
Â
business
 lines
Â
Â
â˘âŻ Quirk
 Healthcare
 Solu7ons
 has
 teamed
 with
Â
NextGen
 to
 develop
 a
 Medicare
 Advantage
Â
suite
 of
 templates
Â
ââŻEnsure
 capture
 of
 HCC
 scores
 and
 assist
 in
Â
maximizing
 5-Ââstar
 scores
Â
â˘âŻ Medicare
 Advantage
 plans
 include
 addi7onal
Â
incen7ves
 to
 supplement
 provider
 income
Â
Â
22. Future
 State
 of
 HCC
 Template
Â
â˘âŻ Panels
 for
 managing
 HCC
 Codes:
Â
â⯠Suspec7ng
 Condi7ons
Â
â⯠Condi7ons
 reported
 by
 Medicare
Â
â⯠Outside
 Condi7ons
Â
â⯠Along
 with
 Adding
 to
 Todayâs
 Assessment
Â
â˘âŻ Op7ons
 to
 Accept,
 Deny
 or
 Work-Ââup
Â
â˘âŻ The
 Medica7on
 Module
 alert
 for
 High
 Risk
Â
Medica7on
 with
 op7on
 for
 prescribing
 non-ÂâHigh
Â
Rick
 Medica7on
Â
â˘âŻ âCase
 Managementâ
 template
 to
 manage
 pa7ent
Â
with
 a
 par7cular
 Diagnosis/HCC
 code
Â