1) The document discusses challenges in healthcare cost containment and the need to base provider payments on quality and efficiency rather than volume.
2) It presents a risk-adjusted payment model using the DCG/HCC system to group diagnoses and adjust provider budgets based on patient risk profiles.
3) Results show the model better predicts hospital admissions counts through linear splines compared to standard distributions, though further refinements are needed to account for coding differences across providers.
Treat EDPS as a Risk Adjustment program…not an IT function. This Episource presentation walks you through the 3 phases of EDPS, and key aspects to keep in mind to run a successful risk adjustment program.
Edifecs- How to ensure RAPS and EDPS submissions equal revenue successEdifecs Inc
The RAPS to EDPS transition for Medicare Advantage plans (MAOs) has now taken on a role of greater importance. CMS has called for an acceleration of the transition with payment determinations in 2017 split 75/25 between RAPS and EDPS.
In this webinar viewers will learn the following:
The RAPS to EDPS transition challenges facing MAOs (some not so obvious)
The cost of the status quo. What you lose by attempting to address encounter submission with a “legacy” approach
How one plan is solving the submission/reconciliation puzzle and experiencing revenue success
What a revenue success checklist for MAOs would contain and how to get started
Surviving the Healthcare World of Risk AdjustmentPYA, P.C.
PYA Principal Bob Paskowski and Senior Staff Consultant Carine Leslie presented a webinar for the Georgia chapter of the Healthcare Financial Management Association Friday, December 16, 2016.
The presentation is tailored for coders in ambulatory/Medicare Advantage settings, providers participating in Medicare Advantage or other risk-based healthcare plans, and leaders in providers’ managed care contracting departments. The webinar is titled “Surviving the Healthcare World of Risk Adjustment.”
The webinar addresses:
• Principles of the Medicare Advantage risk-adjustment model from Medicare Advantage Hierarchical Condition Categories and other risk-based healthcare plans;
• Strategies for reducing compliance risks;
• Methods for accurately, completely, and consistently capturing and documenting a patient’s disease burden to promote effective care management and to reflect the proper risk score.
The Top 9 Questions Every Medical Coder Asks about Risk Adjustment and the CR...Laureen Jandroep
The Top 9 Questions Every Medical Coder Asks About Risk Adjustment and the CRC™ Certification was presented in a webinar by Certification Coaching Org (CCO), www.cco.us. A wealth of information was covered including: what Risk Adjustment (RA) entails, how this field is growing, and RA career opportunities. Also discussed was what to look for in a Risk Adjustment course. Attendees’ questions on careers in RA or preparing for the Certified Risk Adjustment Coder (CRC™) credentialing examination were answered. Presenters were Alicia Scott, CPC, CPC-I, CRC, and Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPC-I, CCS, CANPC, CEMC, CFPC, CIMC, CGSC, COSC, CRC, CCC. The host for the webinar was Boyd Staszewski.
HCC Coding Services: Achieve Accurate HCC Risk Adjustment CodingJessica Parker
CMS uses HCC to compensate Medicare Advantage plans established on the health of their members. It compensates accurately for the anticipated cost expenditures of the patients by adjusting those payments based on demographic information as well as patient as their health status.
Treat EDPS as a Risk Adjustment program…not an IT function. This Episource presentation walks you through the 3 phases of EDPS, and key aspects to keep in mind to run a successful risk adjustment program.
Edifecs- How to ensure RAPS and EDPS submissions equal revenue successEdifecs Inc
The RAPS to EDPS transition for Medicare Advantage plans (MAOs) has now taken on a role of greater importance. CMS has called for an acceleration of the transition with payment determinations in 2017 split 75/25 between RAPS and EDPS.
In this webinar viewers will learn the following:
The RAPS to EDPS transition challenges facing MAOs (some not so obvious)
The cost of the status quo. What you lose by attempting to address encounter submission with a “legacy” approach
How one plan is solving the submission/reconciliation puzzle and experiencing revenue success
What a revenue success checklist for MAOs would contain and how to get started
Surviving the Healthcare World of Risk AdjustmentPYA, P.C.
PYA Principal Bob Paskowski and Senior Staff Consultant Carine Leslie presented a webinar for the Georgia chapter of the Healthcare Financial Management Association Friday, December 16, 2016.
The presentation is tailored for coders in ambulatory/Medicare Advantage settings, providers participating in Medicare Advantage or other risk-based healthcare plans, and leaders in providers’ managed care contracting departments. The webinar is titled “Surviving the Healthcare World of Risk Adjustment.”
The webinar addresses:
• Principles of the Medicare Advantage risk-adjustment model from Medicare Advantage Hierarchical Condition Categories and other risk-based healthcare plans;
• Strategies for reducing compliance risks;
• Methods for accurately, completely, and consistently capturing and documenting a patient’s disease burden to promote effective care management and to reflect the proper risk score.
The Top 9 Questions Every Medical Coder Asks about Risk Adjustment and the CR...Laureen Jandroep
The Top 9 Questions Every Medical Coder Asks About Risk Adjustment and the CRC™ Certification was presented in a webinar by Certification Coaching Org (CCO), www.cco.us. A wealth of information was covered including: what Risk Adjustment (RA) entails, how this field is growing, and RA career opportunities. Also discussed was what to look for in a Risk Adjustment course. Attendees’ questions on careers in RA or preparing for the Certified Risk Adjustment Coder (CRC™) credentialing examination were answered. Presenters were Alicia Scott, CPC, CPC-I, CRC, and Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPC-I, CCS, CANPC, CEMC, CFPC, CIMC, CGSC, COSC, CRC, CCC. The host for the webinar was Boyd Staszewski.
HCC Coding Services: Achieve Accurate HCC Risk Adjustment CodingJessica Parker
CMS uses HCC to compensate Medicare Advantage plans established on the health of their members. It compensates accurately for the anticipated cost expenditures of the patients by adjusting those payments based on demographic information as well as patient as their health status.
Joseph Dal Molin: Implementing VistA internationally: Myth-busting lessons fr...Nuffield Trust
In this slideshow Joseph Dal Molin, President of the E-cology Corporation and Chairman of WorldVistA, outlines Jordan’s health system and its approach to implementing VistA.
Joseph Dal Molin presented at the Nuffield Trust seminar: Sharing international experience: Is implementing the VA's electronic health record system an option for the NHS? in July 2012.
Risk adjustment documentation and coding overviewScott Quick
A collection of information from publicly available sources to help you:
• Know what Risk Adjustment (RA) is and why it is important to Medicare Advantage providers
• Understand Hierarchical Condition Categories (HCCs)
• Become familiar with Risk Adjustment Documentation and Coding Requirements
The vital role of oncology nurses in the care of patients with MM necessitates the awareness of the latest treatment advances and best practices for side-effect management. This CE-certified activity will provide updates in first-line, maintenance, and relapsed/refractory settings. Expert faculty will articulate the diagnosis, cytogenetics, and staging of the disease, as well as promising novel agents and evidence-based best practices for the management of side effects. To provide insight to attendees of the impact of evolving data on a personal level, a patient with MM will share personal perspectives on the journey from diagnosis, treatment, and overall patient experience.
Downloadable slide decks are a great tool for self study and teaching purposes. They are non-certified resources available to enhance your knowledge.
Review a downloadable slide deck by Beth Faiman, PhD(c), RN, APRN, BC, AOCN®, covering the most clinically relevant new data reported from Practical Navigation of a Changing Landscape: Keeping Current on Multiple Myeloma Treatments.
Target Audience
This activity has been designed to meet the educational needs of oncology nurses involved in the care of patients with multiple myeloma (MM).
Slide Deck Disclaimer
This slide deck in its original and unaltered format is for educational purposes and is current as of May 2012. All materials contained herein reflect the views of the faculty, and not those of IMER, the CE provider, or the commercial supporter. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. Readers should not rely on this information as a substitute for professional medical advice, diagnosis, or treatment. The use of any information provided is solely at your own risk, and readers should verify the prescribing information and all data before treating patients or employing any therapeutic products described in this educational activity.
For more information click here:
http://imeronline.com/gxpsites/hgxpp001.aspx?11,52,304,O,E,0,,743;561;8612
Download these clinical tools and resources to improve outcomes in care for patients with multiple myeloma:
http://imeronline.com/gxpsites/hgxpp001.aspx?11,52,304,O,E,0,,743;561;8613
3. Challenges in Cost Containment
Large health insurance company in New England
Current system rewards volume and intensity
Providers lack incentives to focus on quality and
efficiency
y
Payers face escalating costs and in turn pass
onto patients through higher premiums
Need to base payment on outcome to change the
incentives: Risk Adjusted
Quality – standard of care payments to
Efficiency – manage utilization change
behavior
4. Pay-for-performance contract
Global payment
• Adjusted by patients’ health status (
’ (all-encounter DCG
CG
risk score)
• Adjusted by general inflation instead of medical inflation
Performance bonus up if
• Quality g
y goals met (
(standard q
quality measures)
y )
• Efficiency goals met
– risk adjusted cost and utilization targets
Multiyear contract to ensure systematic change
and long-term goals
6. DCG Risk Adjustment System
ICD-9 or ICD-10 Diagnosis Codes
DxGroups (DxGs)
(784 groups)
Impose Hierarchy to
Condition Categories (CCs)
reduce gaming and
(184 groups)
code creep
Aggregated Condition
Categories (ACC )
C t i (ACCs)
(30 groups)
Classify
Classif all diagnosis codes into clinicall meaningf l and
clinically meaningful
homogenous groups for econometric/statistical modeling.
7. Diagnosis Grouping Example
ICD-9 410.01: Initial Anterolateral Acute MI
DxGroup 81.01: acute myocardial infarction, initial
episode of care
CC 81: Acute Myocardial Infarction
ACC 16: Heart
8. Hierarchical Condition Category
(HCC) Example
HCC007 Metastatic Cancer and Acute Leukemia
M t t ti C dA t L k i
HCC008 Lung, Upper Digestive Tract, and Other Severe Cancers
HCC009 Lymphatic, Head and Neck, Brain, and Other Major Cancers
HCC010 Breast, Prostate, Colorectal and Other Cancers and Tumors
HCC011 Other Respiratory and Heart Neoplasm
HCC012 Other Digestive and Urinary Neoplasm
HCC013 Other Neoplasm
HCC014 Benign Neoplasm of Skin, Breast, Eye
9. Example: John Smith has Multiple
Conditions
Substance
Abuse Diabetes Heart
HCC015
HCC020
Diabetes with
Type I Diabetes
Renal
Mellitus
Manifestation
HCC016
Diabetes with
Neurologic or
Peripheral
+ +
Circulatory
Manifestation
HCC017
Diabetes with
Acute
Complications
HCC018
Diabetes with
Ophthalmologic
Manifestation
HCC019
Diabetes with No
or Unspecified
Complications
10. Risk Adjustment Software
j
Demog Diags, Proc Lab, Survey…
Clinical Detail
Database
Data Quality Checks & Tables
Clinical Mapping
& Predictions
Business Solutions
Report Set
11. Predict Future Total Healthcare
Expenditure Using Medical Diagnosis
John Smith
Age: 45
Sex: M
Hypertension
essential hypertension
Type II Diabetes Mellitus
type II diabetes w/ renal manifestation
Congestive Heart Failure
hypertension heart disease, w/ heart failure
disease
Drug/Alcohol Dependence
6.35x sicker than alcohol dependence
average
Relative Risk Score: 6 3
i i S 6.35