March	
  21,	
  2014	
  
Commercial	
  Market	
  &	
  
Health	
  Insurance	
  
Exchanges	
  
	
  
©2013	
  
!  Increased	
  to	
  4.24	
  M	
  thru	
  Feb	
  	
  
!  3.3M	
  Through	
  Jan	
  
>  38%	
  State	
  Based	
 ...
©2013	
  
3	
  
Enrollment	
  by	
  Metal	
  Level	
  
Bronze	
   Silver	
   Gold	
   PlaSnum	
   Catastrophic	
  
18%	
  ...
©2013	
  
!  Financial	
  Assistance	
  
>  83%	
  of	
  Marketplace	
  enrollees	
  are	
  
receiving	
  financial	
  assi...
©2013	
  
!   Marketplace	
  closes	
  
!   Off-­‐Exchange	
  enrollment	
  
!   Small	
  group	
  roll-­‐in	
  
>  Adding	...
©2013	
  
Regulatory	
  Requirements	
  
6	
  
©2013	
  
7	
  
ComparaSve	
  Summary	
  of	
  Risk	
  Adjustment	
  Models	
  
MEDICAID	
   COMMERCIAL	
   MEDICARE	
  
F...
©2013	
  
8	
  
ACA	
  –	
  MA	
  RADV	
  Comparison	
  
	
  	
  
Commercial	
  
ACA	
  RADV	
  
Medicare	
  
MA	
  RADV	
...
©2013	
  
!   Select	
  one	
  or	
  more	
  IVA’s	
  by	
  March	
  31	
  each	
  year	
  
!   Validate	
  IVA	
  qualific...
©2013	
  
10	
  
RADV	
  &	
  Funds	
  Transfer	
  Timing	
  
!   Two-­‐year	
  cycle	
  
!   ProspecSve	
  adjustment	
  ...
©2013	
  
!   Data	
  Accuracy	
  ImperaSve	
  
>  Validates	
  ALL	
  data	
  related	
  to	
  the	
  risk	
  score	
  ca...
©2013	
  
!   Risk	
  Adjustment	
  
>  Focus	
  on	
  aspects	
  not	
  included	
  in	
  RADV;	
  plan	
  type	
  is	
  ...
©2013	
  
13	
  
Audit	
  OperaSons	
  Checklist	
  
FuncSon	
   Risk	
  &	
  RADV	
  Vulnerability	
   OperaSonal	
  Cons...
©2013	
  
!   Following	
  established	
  Edge	
  server	
  communicaSons	
  with	
  HHS,	
  
issuers	
  are	
  expected	
...
©2013	
  
!   Default	
  risk	
  adjustment	
  charge;	
  several	
  opSons	
  
proposed	
  
>  Failure	
  to	
  set	
  up...
©2013	
  
!   Member	
  scoring	
  occurs	
  at	
  the	
  issuer	
  level;	
  	
  	
  
>  risk	
  scores	
  follow	
  the	...
©2013	
  
TargeSng	
  Strategy	
  
©2013	
  
!   Beyond	
  Risk	
  Adjustment:	
  	
  RetenSon	
  and	
  Care	
  Management	
  
!   Historically	
  reported	...
©2013	
  
AdjusSng	
  PrioriSes	
  for	
  Prevalence	
  
HCC	
   HCC	
  Dx	
  Group	
  Label	
  
Weight
Exp	
  
Value
HCC	...
©2013	
  
20	
  
Commercial	
  Risk	
  Adjustment	
  IntervenSon	
  Strategy	
  
• Outreach	
  &	
  Survey	
  
• Targeted	...
©2013	
  
!   High	
  HCC	
  scores	
  create	
  economic	
  value	
  when	
  the	
  cost	
  of	
  
care	
  is	
  managed	...
©2013	
  
!   Managing	
  mulSple	
  risk	
  models:	
  Medicare,	
  Medicaid,	
  
Commercial	
  
!   Market	
  changes	
 ...
©2013	
  
!   Edge	
  server	
  data	
  transformaSon	
  
>  Adjust	
  infrastructure	
  	
  to	
  capture	
  new	
  requi...
877.461.0415	
  |	
  Info@AltegraHealth.com	
  |	
  AltegraHealth.com	
  
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Commercial: Hurry Up and Wait - Where to Focus Efforts as the Exchange Markets Unfold

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Commercial: Hurry Up and Wait - Where to Focus Efforts as the Exchange Markets Unfold

  1. 1. March  21,  2014   Commercial  Market  &   Health  Insurance   Exchanges    
  2. 2. ©2013   !  Increased  to  4.24  M  thru  Feb     !  3.3M  Through  Jan   >  38%  State  Based  Marketplace:  1.6M   >  62%  Federally  Facilitated  Marketplace:   2.6M   !  25%  ages  18-­‐34  (young  invincibles)   !  45%  male;  55%  female           Overall  Enrollment  
  3. 3. ©2013   3   Enrollment  by  Metal  Level   Bronze   Silver   Gold   PlaSnum   Catastrophic   18%   63%   11%   6%   1%   Bronze   Silver   Gold   PlaSnum   Catastrophic   15%   66%   10%   5%   4%   Overall  Enrollment  by  Metal  Level             Young  Invincibles  by  Metal  Level    
  4. 4. ©2013   !  Financial  Assistance   >  83%  of  Marketplace  enrollees  are   receiving  financial  assistance   – 81%  State  Based;  85%  Federal  Facilitated   >  74%  with  financial  assistance  selected  a     Silver  plan   !  Without  Financial  Assistance   >  26%  Silver  plan   >  30%  Bronze  plan   Marketplace  &  Financial  Assistance  
  5. 5. ©2013   !   Marketplace  closes   !   Off-­‐Exchange  enrollment   !   Small  group  roll-­‐in   >  Adding  to  the  risk  pool   >  Mandate  postponed  &  revised  again   !   SHOP  making  it’s  début   !   Looking  to  next  year   >  TransiMonal  policies  conMnue   >  Fall  ElecMons   >  Open  Enrollment:  Nov  15  through  Feb  15   The  Rest  of  the  Enrollment  Story  
  6. 6. ©2013   Regulatory  Requirements   6  
  7. 7. ©2013   7   ComparaSve  Summary  of  Risk  Adjustment  Models   MEDICAID   COMMERCIAL   MEDICARE   Funding  Budget   Plan  Revenue  Impact   Risk  Model   New  Enrollee  Timing   Payment  Structure   Risk  Pools   Scoring  Requirement   Submission  Protocol   Score  Timing   Audits   State  budget  neutral;   Affects  future   reimbursement   ACG(4);  CRG(1);  CDPS(18);   MRX(6);  ERG(1);  DxCG(1)     Varies  3-­‐6  mos   ProspecMve;  Aggregate   Varies  by  aid  category   Diagnosis  codes;  pharmacy   Varies  by  state   Annual;  Semi-­‐annual   Limited   Annual   Annual  by  April  30   CMS  XML  format    on  Edge  server   Paid  claims  diagnosis   codes  +  procedures  codes   Community;  metal  level   Concurrent;  aggregate   Immediate   CMS  Commercial  HCC;   except  MA   Funds  transfer   between  plans   Government  unappropriated;   Plans  subsidize  one  another   Government  funded;   Balanced  to  FFS   No  downside  to   underesMmate  RAF   CMS  HCC/Rx  HCC;   ESRD   12  mos   ProspecMve;  Individual   Community;     InsMtuMonal,  ESRD   Diagnosis  codes   Jan/Mar/Sept   Sporadic  RADV   RAPS  submission;   Encounters  soon   ICD-­‐10   Ouch!  
  8. 8. ©2013   8   ACA  –  MA  RADV  Comparison       Commercial   ACA  RADV   Medicare   MA  RADV   Commercial   ACA  RADV   Medicare   MA  RADV   Audit   EnSSes   • MulMple  independent  IVA’s  may   be  cerMfied   • SVA  may  be  CMS  or  designee   CMS;   contracted   to  HMS   DocumentaSon     Enrollment,  medical  record,   claims     Medical   record  only   Audited   data   All  risk  adjusMng  data:    HCC  +   demographics  +  claims  (poss)   HCC  only   DocumentaSon   per  enrollee     • IVA  requires  yet  unspecified   qty  of  records  per  enrollee;     • SVA  uses  IVA  docs,    no   addiMonal  records  submiied   Up  to  5  in   rank  order   of  best     Sample   Data   Criteria   • De-­‐idenMfied    Edge  data   • 1/3  w/o  HCC’s   CMS  data;  12   mos  MA   enrollment   Sample  Size   200  per  issuer  per  state  for   2014-­‐15     201   enrollees   Sample   • 9  strata:  age  bands  &  risk  level;  1   strata  wi/o  HCC’s   • Uses  issuer  actual  data   • 3  risk  levels   •   Uses  issuer   actual  data   DOS/Provider   Match   Appears  to  be  a  criteria   Not   required     CalculaSng   error  rate   • Error  =  any  change  in  risk  score   • By  the  IVA   • Finalized  by  the  SVA:  IVA/SVA   comparison   Issuer   submits  docs   to  CMS,  CMS   calculates     ApplicaSon  of   Error  rate   • Applied  to  each  issuer’s  plan   in  the  state;   • ProspecMve  year’s  funds   transfer  formula  adjusted;       Individual   at  issuer   level   Non-­‐ compliance   • Default  error  rate  (highest  poss)   • Civil  penalMes:  issuer  &  IVA     • Fraud  prosecuMon       Funding   Issuer  funds  IVA   CMS  
  9. 9. ©2013   !   Select  one  or  more  IVA’s  by  March  31  each  year   !   Validate  IVA  qualificaSons:  cerSfied  coders,  HIPAA,     !   Akest  to  the  absence  of  conflict  of  interest     >  Issuer  financial  ownership,  material  interest,  board/ leadership,  family   >  IVA  has  no  role  in  any  “relevant  internal  controls  or   serve  in  an  advisory  capacity  related  to  the  RADV   >  Obtain  equivalent  aiestaMon  from  the  vendor   !   Fund  the  IVA  audit   !   ParScipate  in  mulSple  states  if  applicable   !   Cross  walk  de-­‐idenSfied  sample  to  enrollee  data,  source   enrollment  and  medical  records   !   Securely  provide  data  to  IVA   !   Establish  and  manage  IVA  Smeframes   9   Issuer  Requirements  
  10. 10. ©2013   10   RADV  &  Funds  Transfer  Timing   !   Two-­‐year  cycle   !   ProspecSve  adjustment  to  funds  transfer   Yr Operations Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 2014 2014  Benefit  Year 2015  Benefit  Year 2015  Data  Activities Rec  Funds   Chg/Pay  2014   data 2015  Audit  Activities Submit  IVA   to  CMS   Receive  2014   Sample Begin   2014  SVA 2016  Benefit  Year 2016  Data  Activites Rec  Funds   Chg/Pay  2015 Adj  for  2014   RADV Submit   2015  IVA  to   CMS Receive  2015   Sample Begin   2015  SVA 2014  Benefit  Year 2016  Benefit  Year IVA  2015  Data:  results  to  CMS  Dec  1 2015 2016 2016  Audit  Activities Finalize  Edge  server  2014  data IVA  2014  Data:  results  to  CMS  Dec  1 SVA  2014  Data SVA  2014  findings   &  appeals Finalize  Edge  server  2015  data 2015  Benefit  Year
  11. 11. ©2013   !   Data  Accuracy  ImperaSve   >  Validates  ALL  data  related  to  the  risk  score  calculaMon:   demographics,  health  status  and  possible  enrollment  and   claims   >  De-­‐idenMfied  sample  requires  reliable  common  files   >  DOS  and  provider  matching  –  precision  claims  processing   >  OperaMonal  planning:  correct  all  errors   !   IVA  documentaSon  selecSon  process  cannot  be   underesSmated   !   Financial  projecSons  for  funds  transfer  formula   !   Plan  for  addiSonal  scruSny   >  Enrollment   >  Subsidies   >  False  Claims  Act  prosecuMon     11   ACA-­‐RADV  Process  CauSons  
  12. 12. ©2013   !   Risk  Adjustment   >  Focus  on  aspects  not  included  in  RADV;  plan  type  is  risk   adjusMng,  renewal  data,  plan  size   !   Reinsurance   >  Targeted  contributors:  Enrollment  counts,  covered  lives   and  payments   >  Targeted  issuers:  plan  eligibility,  claims  (Edge  data)   !   Risk  Corridor   >  Robust  audit  (protecMng  federal  funds)  aligned  with   MLR  audit   >  ValidaMon  check  for  enrollment  and  premiums  on  the   Edge  server   >  Targeted  contributors  (est  1%);  Targeted  issuers  (est   5%)   12   Other  Audits  
  13. 13. ©2013   13   Audit  OperaSons  Checklist   FuncSon   Risk  &  RADV  Vulnerability   OperaSonal  ConsideraSons   Edge  Server   Data   • Correct  all  errors   • De-­‐idenMficaMon  crosswalk   • Claim-­‐DOS  Match   Create  pre-­‐validaMon  rules     Enrollment   • Availability  of  data     • Grace  period   • Plan  changes   Include  enrollment  audit  with   retrospecMve  process     Claims  Systems   • Custom  business  rules   • Void/replace  process;  parMal  denials   • Interim  bills   • ICD-­‐10  conversion   Incorporate  into  Edge  server  pre-­‐ validaMon  rules   Risk   Adjustment   • Enrollment  Mming   • ICD-­‐10  transiMon   • Supplemental  data  submission   Assume  assessments  and  retro   charts  are  audited;  delete  codes  &   linked  supplemental  data     Providers   • ICD-­‐10  TransiMon   • Chart  retrieval  volume   • DocumentaMon  accuracy   IncenMves  for  chart  access;     Provider  panel  evaluaMon   Finance   • Audit  funding   • Funds  transfer  projecMons   Crack  open  the  piggy  bank   Compliance   • Audit  staffing   Evaluate  internal  resources  
  14. 14. ©2013   !   Following  established  Edge  server  communicaSons  with  HHS,   issuers  are  expected  to  submit  quarterly:  “complete  and   current  enrollment  file  and  a  good  faith  effort  for  accurate   and  current  claims  files”   >  TransacMonal  process  report—issuer  required  to  correct   or  accept  the  rejecMon   >  CMS  expects  issuers  to  proacMvely  idenMfy  and  correct  risk   adjusMng  claims     !   CMS  provided  interim  report   >  Preliminary  risk  scores  &  aggregated  claims  for   reinsurance   !   Issuer  response  required     >  Interim  report  30  days;       >  15  days  for  final  report  issued  before  June  30   14   Distributed  Data  Requirements  Clarified  
  15. 15. ©2013   !   Default  risk  adjustment  charge;  several  opSons   proposed   >  Failure  to  set  up  an  Edge  server   >  Inadequate  Data   >  PMPM  based  on  a  fixed  %  of  the  state-­‐wide   average  premium  and  enrollment  based  on   MLR  or  risk  corridor  or  “other”   !   Supplemental  data  submission   >  Delete  codes   >  Linked  to  a  paid  claim   15   AddiSonal  Distributed  Data  Requirements  
  16. 16. ©2013   !   Member  scoring  occurs  at  the  issuer  level;       >  risk  scores  follow  the  member  within  the  issuer   >  Requires  adequate  re-­‐idenMficaMon  process   >  Not  linked  across  issuers  owned  by  the  same  company   !   DOS  clarificaSon:  must  match  the  enrollment  period   !   Grace  period  claims  will  only  be  counted  if  not  retro   terminated   >  Create  an  error  workflow  for  this  process   !   No  change  to  the  geographic  cost  factor  calculaSon   !   Small  group  counSng  methodology  consistent  with  SHOP   methodology   !  Small  groups  that  become  large  can  conMnue  in  risk  adjustment     16   Funds  Transfer  Formula  ClarificaSons  
  17. 17. ©2013   TargeSng  Strategy  
  18. 18. ©2013   !   Beyond  Risk  Adjustment:    RetenSon  and  Care  Management   !   Historically  reported  diagnoses  is  NOT  enough   !   High  confidence  level  important  to  minimize  provider  &  member  abrasion   >  Transparent  model  that  is  edited  based  on  results   !   Supplemental  Data   >  External  data  sources  based  on  enrollee  demographics   !   Pharmacy  Data   >  177,000  +  NDC’s  requires  consolidaMon  to  generic  product  indicator   !   Client  Data  AddiSons   >  Self-­‐reported  condiMons  (health  survey)   >  Third  party  data,  such  as  underwriMng  data   >  Prior  AuthorizaMon  data;    Care  Management  data     !   Overall  model  modifiers   >  Prevalence  rates   >  Chronicity   >  Code  Recoverability;  Provider  coding  paierns   18   TargeSng  AnalyScs:  Data  Sources  
  19. 19. ©2013   AdjusSng  PrioriSes  for  Prevalence   HCC   HCC  Dx  Group  Label   Weight Exp   Value HCC   HCC  Dx  Group  Label   Weight Exp   Value HDX21 Hematological  Disorders 49.8 149.5 HDX21 Hematological  Disorders 49.8 149.5 HDX39 Severe  Respiratory  Conditions 40.1 40.1 HDX05 Cancer 25.2 75.5 HDX54 Renal  Disease 37.7 37.7 HDX39 Severe  Respiratory  Conditions 40.1 40.1 HDX40 Heart  Assistive  Device/Artificial  Heart  (G14)33.7 33.7 HDX11 Peritonitis/Gastrointestinal  Perforation/Necrotizing13.1 39.4 HDX05 Cancer 25.2 75.5 HDX54 Renal  Disease 37.7 37.7 HDX07 Protein-­‐Calorie  Malnutrition 14.8 14.8 HDX23 Addiction  (G09) 3.8 34.0 HDX02 Septicemia,  Sepsis,  Systemic  Inflammatory  Response  Syndrome/Shock13.7 13.7 HDX40 Heart  Assistive  Device/Artificial  Heart  (G14)33.7 33.7 HDX11 Peritonitis/Gastrointestinal  Perforation/Necrotizing  Enterocolitis13.1 39.4 HDX04 Opportunistic  Infections 9.7 29.0 HDX48 Arterial  Disease 11.9 11.9 HDX53 Aspiration  and  Specified  Bacterial  Pneumonias  and9.1 27.2 HDX42 Ischemic  Heart  Disease 11.9 11.9 HDX15 Arthropathy  /  Osteopathy  (G03) 7.9 23.6
  20. 20. ©2013   20   Commercial  Risk  Adjustment  IntervenSon  Strategy   • Outreach  &  Survey   • Targeted  Appointment   Assistance   • Outreach  &  Survey  –   mulSple  akempts   • Appointment  Assistance   &  IncenSve   • Retro  Chart  Review   • Outreach  condiSon-­‐based   • Appointment  Assistance  &   IncenSve   • Concurrent  Chart  Review   • Home  Assessment  (?)   • Outreach  &  Survey     • Outreach  &  Survey  –   mulSple  akempts   • Appointment  Assistance   • Outreach  condiSon-­‐based   • Appointment  Assistance  &   IncenSve   • Retro  Chart  Review   • Outreach  &  Survey     • Outreach  &  Survey     • Outreach  condiSon-­‐based   • Appointment  Assistance  &   IncenSve                                                                          Risk  Score  Gap                Low                                                                Med                                                      High   PredicSve  AnalyScs  Confidence  Level                Low                                                                                  Med                                                                  High   Supplemental                                                                Rx                                              Prevalence  &  Survey                                             Messaging  Variables       •  Chronic  condiMon   •  Subsidy   •  Metal  Level   •  New  to  the  Plan   4%   12%   30%   55%  50%  of  total   populaSon  
  21. 21. ©2013   !   High  HCC  scores  create  economic  value  when  the  cost  of   care  is  managed   !   Data  accuracy  required:    enrollment,  claims,  edge  server   !   Enrollees  with  high  costs  and  missed  HCC’s  cause  economic   loss   !   ACA-­‐RADV  has  material  impact   >  Provider  documentaMon  and  claims  processing  is  criMcal   >  Expect  annual  adjustments   !   ICD-­‐10   !   Increased  reliance  on  the  provider   >  Provider  claims  processing—for  risk  adjustment  and   audit   >  Provider  documentaMon—for  audit  purposes   >  Provider  coding  errors—affects  risk  adjustment  and   audits       Managing  the  Funds  Transfer  Formula   21  
  22. 22. ©2013   !   Managing  mulSple  risk  models:  Medicare,  Medicaid,   Commercial   !   Market  changes   >  Medicare,  Medicaid,  Commercial  volume  increases   >  New  commercial  market  risk  adjustment   documentaMon  requirements   !   Limited  resources   !   EMR  impact  to  billing  and  risk  scores   !   TransiSon  to  ICD-­‐10  will     >  increase  edits/denials   >  decrease    claim  volume  and  coding  accuracy   !   ICD-­‐10  for  Risk  Adjustment     22   Provider  ConsideraSons  
  23. 23. ©2013   !   Edge  server  data  transformaSon   >  Adjust  infrastructure    to  capture  new  required  data  elements   >  Assess  impact  of  data  erosion  and  errors   >  Evaluate  custom  claims  adjudicaMon  business  rules   !   Outreach  Campaigns   >  Cross  funcMonal  outreach  strategy:  risk  adjustment,  retenMon,   uMlizaMon   !   Analyze  historical    Commercial  PopulaSon     >  Begin  looking  for  data  gaps   !   Provider  financial  impact  planning  &  Engagement  Strategy   >  Provider  panel  analysis   !   ICD-­‐10  risk  adjustment  planning   !   Establish  RADV  compliance  and  operaSons  teams   !   Reinsurance  claims  monitoring   !   Prepare  care  management  teams  based  on  new  plan  benefits  and   populaSon  demographics     Take  AcSon  Now   23  
  24. 24. 877.461.0415  |  Info@AltegraHealth.com  |  AltegraHealth.com   Discussion  

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