Medicare	
  Advantage	
  
Wednesday,	
  March	
  26,	
  2014	
  
Disclaimer:	
  Nothing	
  that	
  we	
  are	
  sharing	
 ...
•  Originated	
  with	
  the	
  Balance	
  Budget	
  of	
  1997	
  
–  Addi7on	
  to	
  Part	
  A	
  &	
  B	
  
•  Part	
 ...
Reimbursement	
  Model	
  
•  Provided	
  by	
  an	
  index	
  per	
  county	
  	
  
•  Plan	
  bids	
  to	
  CMS	
  every...
Reimbursement	
  Example	
  
•  Bid	
  for	
  $500	
  
•  Miami-­‐Dade	
  County	
  index	
  ra7ng	
  $900	
  
•  Balance	...
Hierarchy	
  Condi7on	
  Categories	
  (HCC)	
  
•  Risk	
  Adjustment	
  Factor.	
  
•  Risk	
  Adjust	
  Process	
  Syst...
HCC	
  Code	
  Management	
  and	
  Recer7fica7on	
  
•  Integrated	
  IMO	
  search	
  	
  
– HCC	
  codes	
  	
  
– RxHCC...
★★★★★ Ra7ng	
  
•  Plans	
  rated	
  on	
  1	
  to	
  5	
  
•  Five	
  star	
  ra7ng	
  system	
  created	
  by	
  CMS	
  ...
Monitoring	
  Systems	
  -­‐	
  HEDIS	
  
•  Healthcare	
  Effec7veness	
  Data	
  and	
  Informa7on	
  
Set	
  (HEDIS)	
  ...
Monitoring	
  Systems	
  -­‐	
  CAHPS	
  
•  Consumer	
  Assessment	
  of	
  Healthcare	
  Provider	
  and	
  
Systems	
  ...
Monitoring	
  Systems	
  -­‐	
  Medica7ons	
  
•  Medica7ons	
  
–  Compliance	
  required	
  to	
  ensure	
  pa7ent	
  he...
Meaningful	
  Use	
  (MU)	
  
•  Eligible	
  Professionals	
  
– 80%	
  of	
  services	
  to	
  members	
  of	
  a	
  sing...
Provider	
  Models	
  
•  Contract	
  with	
  provider	
  networks	
  for	
  delivery	
  
of	
  care	
  
•  Provider	
  mo...
Case	
  Study	
  on	
  
Medicare	
  Advantage	
  
The	
  Partnership	
  
•  Leon	
  Medical	
  Center	
  in	
  Florida	
  
– Faced	
  with	
  ul7matum	
  
• Bring	
  organi...
The	
  Turnaround	
  
•  Reshaped	
  organiza7on	
  by	
  focusing	
  on	
  3	
  priori7es:	
  
–  Maintain	
  accurate	
 ...
The	
  Accomplishment	
  
•  Leon	
  Medical	
  Center	
  upgraded	
  the	
  system	
  in	
  2	
  
months	
  to	
  create	...
The	
  Results	
  
•  With	
  the	
  $1	
  million	
  investment:	
  
– Qualifica7ons	
  of	
  all	
  primary	
  care	
  ph...
Medicare	
  Advantage	
  and	
  
NextGen	
  
Medicare	
  Advantage	
  in	
  NextGen	
  
•  HCC	
  Code	
  check	
  
•  Applica7on	
  Configura7on	
  	
  
– Enable	
  HC...
Medicare	
  Advantage	
  in	
  NextGen	
  
Medicare	
  Advantage	
  in	
  NextGen	
  
•  Medicare	
  Advantage	
  one	
  of	
  the	
  most	
  lucra7ve	
  
business	
...
Future	
  State	
  of	
  HCC	
  Template	
  
•  Panels	
  for	
  managing	
  HCC	
  Codes:	
  
–  Suspec7ng	
  Condi7ons	
...
Q&A	
  
dan.holleran@quirkhealthcare.com	
  
tamina.vahidy@quirkhealthcare.com	
  
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Medicare Advantage

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Medicare Advantage is a well-known program, but perhaps not so well-known in its details. In this webinar, we get into the nuts and bolts of how the program works, including a case study with practical examples. If you’d like to offer or improve a Medicare Advantage plan at your facility, this is a good place to start.

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Medicare Advantage

  1. 1. Medicare  Advantage   Wednesday,  March  26,  2014   Disclaimer:  Nothing  that  we  are  sharing  is  intended  as  legally  binding  or  prescrip7ve  advice.  This  presenta7on  is  a   synthesis  of  publically  available  informa7on  and  best  prac7ces.  
  2. 2. •  Originated  with  the  Balance  Budget  of  1997   –  Addi7on  to  Part  A  &  B   •  Part  A  –  Hospitals   •  Part  B  –  Professional     •  Part  C  –  Medicare  Advantage  (MA)   –  Certain  age   –  Disabled   –  Sign  over  benefits  to  a  private  HMO   –  Special  Needs  Plan  for  pa7ents  with  terminal  illness  (e.g.  End-­‐ stage  renal  disease)     –  Eligibility   •  Part  D  –  Medica7ons   Medicare  
  3. 3. Reimbursement  Model   •  Provided  by  an  index  per  county     •  Plan  bids  to  CMS  every  June   – Proposed  capita7on  per  member   – Plan  benefits   – Confiden7al   •  New  packages  announced  in  October   •  Plan  effec7ve  January  1   •  5-­‐Star  Plans  get  beSer  enrollment  benefits  
  4. 4. Reimbursement  Example   •  Bid  for  $500   •  Miami-­‐Dade  County  index  ra7ng  $900   •  Balance  split  between  plan  and  Medicare   –  Add  $200   •  Bonus  based  on  star  ra7ng   –  Add  $100   •  Factor  in  Risk  score   –  Mul7ply  by  risk  factor,  e.g.  2   •  Reimbursement  calcula7on:   500  +  200  +100  =  800  *  2  =  $1600  is  reimbursed  
  5. 5. Hierarchy  Condi7on  Categories  (HCC)   •  Risk  Adjustment  Factor.   •  Risk  Adjust  Process  System  file  (RAPS).   •  HCC  must  be  assessed  once  during  a  calendar  year   –  Assessment  must  have  a  corresponding  plan  of  care  within  the   physician  note   •  HCC  codes  must  be  capture  in  the  pa7ent  chart   –  Clinical  Document  Improvement  Specialist     –  Coders   •  8  diagnosis  codes  allowed  under  4010  and  12  diagnosis  under  5010   •  NextGen  8.3  templates  have  unlimited  Diagnosis  codes  capability  with   ICD-­‐10   •  Ability  to  have  claim-­‐splidng  to  submit  more  diagnosis  codes  if  needed  
  6. 6. HCC  Code  Management  and  Recer7fica7on   •  Integrated  IMO  search     – HCC  codes     – RxHCC  code     – Corresponding  Risk  Adjustment  Factor  and  prompt   for  a  second  code  if  needed  to  submit  diagnosis     •  Flag  for  codes  not  recer7fied  in  preceding  year  
  7. 7. ★★★★★ Ra7ng   •  Plans  rated  on  1  to  5   •  Five  star  ra7ng  system  created  by  CMS     •  Ra7ng  system  components  announced  in  June   •  Tangible  benefits  to  increasing  star  ra7ngs:   – Bonus  for  plans  who  achieve  a  4  or  5  stars   – Only  5  star  plans  can  market  and  accept  new   members  year  around   •  Plans  with  historical  low  star  ra7ng  may  be   removed  
  8. 8. Monitoring  Systems  -­‐  HEDIS   •  Healthcare  Effec7veness  Data  and  Informa7on   Set  (HEDIS)   –  Used  by  more  than  90  percent  of  health  plans   –  Measures  performance  on  important  dimensions  of   care  and  service   •  HEDIS  Requirements   – Required  protocols  built  directly  into  the  Disease   Management  tab   – Alerts  when  pa7ents  are  overdue  for  required   tests  
  9. 9. Monitoring  Systems  -­‐  CAHPS   •  Consumer  Assessment  of  Healthcare  Provider  and   Systems  (CAHPS)   –  Survey  to  determine  which  services  were  offered  to   members  by  their  plan   •  Health  Outcome  Survey  (HOS)     –  Survey  to  measure  pa7ent  percep7on  of  plan  effec7veness   •  CAHPS  and  HOS  Flags   –  Cannot  be  influenced  directly  though  the  EHR   –  Flags  can  be  placed  in  the  EHR  for  CAHPS  or  HOS  survey   •  Alert  shown  each  7me  the  pa7ent  is  seen  or  to  help  ensure  that   the  survey  is  returned.  Reports  can  be  run  against  these  alerts  
  10. 10. Monitoring  Systems  -­‐  Medica7ons   •  Medica7ons   –  Compliance  required  to  ensure  pa7ent  health  is   monitored   –  High  Risk  Medica7ons  that  a  pa7ent  is  taking   •  Complica7ons   –  Controlling  medica7ons  dispensing  impera7ve  to  5   star  ra7ng,     •  Leveraging  EHR   –  Clinical  Guidelines  por7on  of  Disease  Management   suggest  medica7on  based  on  disease  protocols   –  Formulary  checking  func7onality  
  11. 11. Meaningful  Use  (MU)   •  Eligible  Professionals   – 80%  of  services  to  members  of  a  single  plan     – MU  requirements  for  MA  same  as  Part  B   providers.     •  Do  not  need  to  submit  on  Clinical  Quality   Measure  (CQM)     •  Reimbursements  paid  directly  to  the  plan   •  Specific  requirements  and  dates  for   registra7on  and  aSesta7on  
  12. 12. Provider  Models   •  Contract  with  provider  networks  for  delivery   of  care   •  Provider  model  can  either  be:   – Staff     – IPA  
  13. 13. Case  Study  on   Medicare  Advantage  
  14. 14. The  Partnership   •  Leon  Medical  Center  in  Florida   – Faced  with  ul7matum   • Bring  organiza7on  live  on  NextGen  in   6  months  for  $1  million  or  lose  MA   contract   •  Team  approach  to  op7mizing  Medicare   Advantage  system  and  procedures  
  15. 15. The  Turnaround   •  Reshaped  organiza7on  by  focusing  on  3  priori7es:   –  Maintain  accurate  Risk  Score  for  each  pa7ent   –  Improve  the  quality  ra7ng     •  Health  Screening   •  Chronic  Condi7ons   •  Consumer  sa7sfac7on   –  Control  Costs  through  u7liza7on  management   •  Implementa7on  strategy:   –  Build  a  strong  team   –  Ensure  providers  comply  with  coding  guidelines   –  Establish  workflows  that  support  quality  improvements   –  Implement  technology  that  supports  established  standards  and   procedures  
  16. 16. The  Accomplishment   •  Leon  Medical  Center  upgraded  the  system  in  2   months  to  create  a  live  produc7on   environment   •  Brought  live  100  physicians  in  7  loca7on  in  4   months   •  Tracked  progression  via  go-­‐live  scorecard   aligned  with  goals  
  17. 17. The  Results   •  With  the  $1  million  investment:   – Qualifica7ons  of  all  primary  care  physicians  for   Meaningful  Use  program   •  $2  million  in  reimbursements  from  CMS   – A  .2%  increase  in  the  organiza7ons  CMS  Risk   Adjustment  Factor   – Awarded  5-­‐Star  ra7ng  by  CMS   •  Per-­‐capita  bonus  that  is  rolled  back  into  the  clinical   service  for  members   •  Year-­‐round  member  enrollment  
  18. 18. Medicare  Advantage  and   NextGen  
  19. 19. Medicare  Advantage  in  NextGen   •  HCC  Code  check   •  Applica7on  Configura7on     – Enable  HCC  in  Prac7ce  Preferences.   – EHR  Master  Files  –     •  System    Prac7ce    Prac7ce  Preferences    Charge   Entry    Differen7ate  Risk  Adjust  Diagnosis   •  “Enable  HCC  for  this  pa7ent”  checkbox  on   *Intake   – Makes  HCC  buSon  visible  
  20. 20. Medicare  Advantage  in  NextGen  
  21. 21. Medicare  Advantage  in  NextGen   •  Medicare  Advantage  one  of  the  most  lucra7ve   business  lines     •  Quirk  Healthcare  Solu7ons  has  teamed  with   NextGen  to  develop  a  Medicare  Advantage   suite  of  templates   – Ensure  capture  of  HCC  scores  and  assist  in   maximizing  5-­‐star  scores   •  Medicare  Advantage  plans  include  addi7onal   incen7ves  to  supplement  provider  income    
  22. 22. Future  State  of  HCC  Template   •  Panels  for  managing  HCC  Codes:   –  Suspec7ng  Condi7ons   –  Condi7ons  reported  by  Medicare   –  Outside  Condi7ons   –  Along  with  Adding  to  Today’s  Assessment   •  Op7ons  to  Accept,  Deny  or  Work-­‐up   •  The  Medica7on  Module  alert  for  High  Risk   Medica7on  with  op7on  for  prescribing  non-­‐High   Rick  Medica7on   •  “Case  Management”  template  to  manage  pa7ent   with  a  par7cular  Diagnosis/HCC  code  
  23. 23. Q&A   dan.holleran@quirkhealthcare.com   tamina.vahidy@quirkhealthcare.com  
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