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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.
• 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
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
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
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
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
★★★★★ 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
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
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
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
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
Provider Models
• Contract with provider networks for delivery of care
• Provider model can either be: – Staff – IPA
Case Study on Medicare Advantage
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
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
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
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
Medicare Advantage and NextGen
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
Medicare Advantage in NextGen
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
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
