5. About Medicare
5
In-patient
SNF
Home health
Hospice
Provider services - office visits
Out patient screenings - preventive
Hospital emergency - ambulance
Supplies - durable med-equipment
Medicare
Advantage Plans
Includes Part A & B
Pharmacy benefits
Additional services
Other
6. What is Risk Adjustment?
A method used to
predict costs and
adjust payment based
on member’s health
status and based on
the relative risk of the
patient’s health status
Hierarchical Condition Category (HCC)
7. It is used to prospectively adjust payment based
on health status and characteristics of a enrollee
Compares beneficiary to average Medicare beneficiary
What is Risk Adjustment?
8. What is RAF?
8
Risk Adjustment Factor (RAF)
RAF is a calculation to predict the cost of care for
beneficiaries
RA score is determined by using all relative factors of
one patient for a total year
Demographic and disease information to predict
future healthcare costs
A higher score represents the sickest patients
9. Risk Adjusted Model
Implemented by CMS by the Balanced Budget
Act of 1997
Model collects information to establish cost of
future patient care
CMS “risk model” is based on measuring
chronic conditions
11. Developed by CMS for risk
adjustment of the Medicare
Advantage Program (Part C)
CMS has an RX HCC model for risk
adjustment of Medicare Part D
Medicare - based on age 65 or older
Current year data predictive of
future year risk
CMS - HCC
12. Developed by the Department of
Health and Human Services (HHS)
Designed for the commercial payer
population
HHS-HCCs predict the sum of
medical and drug spending
Includes all ages
HHS - HCC
14. HCC Program Summary
14
Medicare Advantage Plans – Part C
Medicare Shared Savings ACO (expected cost)
Value-Based Purchasing (expected cost/efficiency)
Medicaid
Health Insurance Exchange Plans
Commercial carriers
Offers total score for Value Based Purchasing,
population health, risk and cost prediction
15. Why Do Providers Care?
15
STEP 1 - Physician/hospital must document
clinical information based on HCC code set
Step 1
16. Why Do Providers Care?
16
STEP 2 - HHS and CMS uses claims data to
calculate a patient’s risk score for documentation,
coding and billing
Step 2Step 1
17. Why Do Providers Care?
17
STEP 3 - CMS pays insurance payer for HCC
accuracy based on providers documentation
and coding
Step 3Step 2Step 1
18. Why Do Providers Care?
18
Step 4
Step 3Step 2Step 1
STEP 4 - Payer pays provider based
on correct HCC codes - accuracy
means more revenue for provider
19. Why Do Providers Care?
19
CMS audits to ensure integrity and accuracy of
risk-adjusted payment – compliance risk
Medicare Advantage plans can be selected for
RADV Audits annually to validate diagnosis
Providers are required to assist in RADV Audits
RISK ADJUSTMENT
DATA VALIDATION
AUDITS (RADV)
20. Why Do Providers Care?
20
HCC reimbursement rates are increasing over the
next three years
There is a financial benefit to the provider and payer
for correctly capturing all HCC codes
There are approximately 10,000 codes that map to
HCCs that need to be understood and captured
21. Why Do We Care?
21
HCC is now on the provider’s
radar
We can audit medical
records to find gaps in HCC
coding
Reduce provider risk due to
a lack of compliance
We can assist providers with
clinical documentation and
education
22. MiraMed HCC Services
22
Provide retrospective audits
current timeframe or lookback
12 months
Identify and document missed
HCC codes to increase provider
revenue
Offer year-end, quarterly or
ad- hoc auditing
Provide on-site CDI education
and training services
23. Delivering HCC Services
23
Use all offshore auditors with a
ramp up timeframe of 60 to 90
days
Use all onshore auditors
supplied by MMOC
Use MMOC auditors for quick
ramp up and supplant US
coders with our offshore team
24. Prospect Contacts
24
Hospital
CFO
VP Revenue Cycle
VP of Managed Care
Manage Care Executive
VP of Coding
Physician Group
Manage Care Executive
Group Administrator
ACO Executive Director
25. Value Proposition
25
36 year successful revenue cycle
track record
15 years of coding experience
Code over 30 million charts
annually – all specialties
Deliver consistent 95 % accuracy
Team’s experience: MD, RN,
AHIMA/AAPC Certified - CPC,
CPMA, CPCO, CEDC, CCS, CCS-P,
CIC, CPMA, AHIMA ICD-10-
CM/PCS Trainers
PHIL
- Good afternoon and welcome to our webinar, Patient Payment Liability Trends and Collection Solutions.
- My name is Phil Solomon, I am your host along with my esteemed colleague Lyman Sornberger.
- This webinar is brought to you by MiraMed, a trusted leader in healthcare business processing outsourcing and by Capio Partners, a leading healthcare asset purchaser.
- I’d like to thank Lorman Education for inviting us to lead this webinar today and most importantly, I’d like to thank our participants for taking the time out of your busy schedule to attend our webinar.
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
PHIL
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
Our healthcare system has undergone sweeping changes since the passing of the Patient Protection and Affordable Care Act, passed on March 23rd 2010.
The industry has become a lightening rod for controversy, and one reason is the expenditures for our healthcare. $3.2 Trillion equals 18% of our entire GDP, which is the monetary value of all the goods and services produced in the US
As our budget deficit has grown, so has healthcare spending, 5.3% in 2014. Growth from 2010 – 2013 was down sharply by 78% from the 1980s
England’s entire GDP is less than we spend on our healthcare
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
- Revenue cycle performance is challenging because:
- No other industry has the type of complexity – Medicare, Medicaid, regional and local payment sources
- Clinical, operational and financial cross departmental involvement
-
PHIL
Business to business which is provider to payer has changed to business to consumer billing and payment
Big box healthcare is CVS, Walmart, Walgreens, etc.
PHIL
Business to business which is provider to payer has changed to business to consumer billing and payment
Big box healthcare is CVS, Walmart, Walgreens, etc.
PHIL
Business to business which is provider to payer has changed to business to consumer billing and payment
Big box healthcare is CVS, Walmart, Walgreens, etc.
PHIL
Business to business which is provider to payer has changed to business to consumer billing and payment
Big box healthcare is CVS, Walmart, Walgreens, etc.