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Tag Archives: risk adjustment
Do you know your level of exposure for overpayment recovery from CMS?
On March 3, 2015, Cheri Rice, CMS’ Director of Medicare Plan Payment Group, released a memo notifying all Medicare Advantage Organizations, PACE Organizations, and certain Demonstrations of its intent to rerun risk scores during the calendar year 2015. If you read this memo and muttered, “uh oh” under your breath, you might be thinking that your plan/organization owes CMS some money, and soon. If you haven’t read this memo, “uh oh” would be an understatement.
Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company’s risk adjustment coding and data collection practices. The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act. The company has over 3.2 million Medicare Advantage members.
Seriously, the first question is, “what do you have under the hood for risk adjustment in your health plan?” If you’re running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don’t have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it’s not just plans on the Exchanges, it’s all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!
Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat sheet, no best practices for all things healthcare, and we cannot succeed if we have too many strategies. Let’s compare five areas: Read more
What we learned in Medicare + Choice is still true today, we don’t need narrow provider networks; we need aligned provider networks, aka Smart Networks. We have also learned that narrow networks often cause ill-will with your health systems and uncontrolled leakage. A Smart Network builds a mini-healthcare community similar to an ACO in your healthcare delivery ecosystem. A Smart Network can focus on a health system and it’s provider feeder system or it can better engage your Primary Care Physicians (PCP) and “rendering” PCP. Smart Networks typically are invisible to members; however some payers may differentiate copay to encourage Smart Network utilization.
The January 1 legislation to fix the fiscal cliff postpones the scheduled 27 percent Medicare physician fee schedule cut under the Sustainable Growth Rate formula for one year. In order to pay for the doc fix, there are a number of payment reductions to Medicare fee for service providers, especially reductions in hospital and ESRD payments, and an extension of the DME competitive bidding program to diabetes test strips purchased at retail pharmacies. The Medicare Advantage (MA) program also takes a hit. The legislation saves $2.5 billion over ten years by adjusting the MA risk adjustment methodology to increase the coding intensity adjustment factor for 2014 from 1.3 percentage points to 1.5 percentage points and to increase the adjustment factor for 2019 and subsequent years from 5.7 percent to 5.9 percent. The coding intensity adjustment is intended to reflect different coding patterns between Medicare Advantage plans and FFS providers.