THE EVER-GROWING COMPLEXITY OF RISK SCORE ... - Ciox Health · Risk adjustment is the method used...

JESSICA SMITH

Senior Vice President, Healthcare Analytics & Risk Adjustment

THE EVER-GROWING COMPLEXITY OF RISK SCORE CALCULATION – 2019 & BEYOND

Copyright © 2018 Gorman Health Group2

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AGENDA

Risk Adjustment Overview

Data Submissions• RAPS• EDPS• Transitional Impacts

Cures Act on Risk Adjustment

2019 Risk Adjustment Model Changes


Risk adjustment is designed to evaluate the risk of

the members enrolled in a plan and accordingly

compensate the issuer based on the amount of risk

they carry for the health plan, utilizing the members’

demographics and diagnosis information.

WHAT IS RISK ADJUSTMENT ?


COMPONENTS OF RISK ADJUSTMENT

Medical Record Review

Initiatives & Interventions

Data Submission & Reconciliation

Vendor Collaboration & Oversight

Provider Engagement

Financial Reporting

CMS & Internal Auditing

Strategy Operational Infrastructure Analytics


FLOW OF DATA FOR SUBMISSION


SUBMISSION PROCESS

In Reality……….


WHAT IS RAPS?

RAPS = Risk Adjustment Processing System

Risk adjustment is the method used to adjust bids and payments to health plans based on demographics (e.g., age and gender) as well as actual health status of a plan’s enrollees.

Medicare risk adjustment is prospective, meaning diagnoses from the previous year and demographic information are used to predict future costs and adjust payment.


RAPS DATA HAS LITTLE DETAIL

HICN

or

MBI

Provider Type

Service From Date

Service Thru Date

Delete Indicator

Risk Assessment

Code

Diagnosis


WHAT IS ENCOUNTER DATA?

EDPS = Encounter Data Processing System

Encounter data is detailed data generated by healthcare providers, such as doctors and hospitals, which documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries to treat these conditions.

The Centers for Medicare & Medicaid Services (CMS) began collecting encounter data from Medicare Advantage plans in 2012.


Medicare Institutional (837I)

Medicare Professional (837P)

Medicare DME

(837P DME) Medicare NCPDP –Part D Pharmacy

WHAT ARE DIFFERENT TYPES OF REQUIRED ENCOUNTER DATA?


CMS currently requires two different file formats:• RAPS files: 7 key data elements,

filtering required• Encounter Data System (EDS) files:

837 format, no filtering

DATA SUBMISSIONS

Goal: Submit complete and accurate data to CMS in a timely manner


Claims should equal RAPS and vice versa

EDPS should equal claims and vice versa

Ideally, RAPS should equal EDPS

FINANCIAL IMPACT

Claims(including supplemental data)

RAPS EDPS


TRANSITION COMPLEXITIES

Implementing a successful EDPS

submission process

Source data issues

File format complications

Supplemental diagnosis

submission difficulty

Linked and unlinked chart

review acceptance

Lack of reliable MAO-004

information

EDPS – MAO-004 data wasn’t

available prior to 10/22/2016

Questionable accuracy of the

MAO-004

Impact of EDPS filtering logic

Difficulty in determining

which risk score decreases are

due to submission

issues vs. CMS filtering logic


TRANSITION OF RAPS TO EDPSTo be continued………

Original Actual

Contract Year RAPS Weight EDPS Weight RAPS Weight EDPS Weight

2020 0% 100% ? ?

2019 25% 75% 75% 25%

2018 50% 50% 85% 15%

2017 75% 25% 75% 25%

2016 90% 10% 90% 10%

2015 100% 0% 100% 0%


Payment Condition Count Model not implemented for 2019

Requested implementation delay• Evaluate impact• Validate results• Provider feedback

21st Century Cures Actinterpretation difference

Plan to implement in 2020

RISK MODEL FINAL RULE

Proposed conditions finalized• Chronic Kidney Disease• Mental Health• Substance Use Disorder

Conditions are clinically meaningful

Predict significant cost

Improve cost prediction

EDPS/RAPS weight changes


Call Letter commenters were supportive of utilizing the updated model but leery about the inclusion of the count model.CMS’ interpretation of the Cures Act:

• “…make an additional adjustment as the number of diseases or conditions of an individual increases.”

Interpretation conflicts:• Some argue the risk adjustment model

already adds co-efficients for individual conditions.

CURES ACT – CONDITION COUNT MODEL


CMS was not required to implement a new risk adjustment model this year.However, CMS felt it was beneficial for 3 primary reasons:• Improves the accuracy of the model for

members who are diagnosed with the newly added HCC categories.

• Updating the data used to calibrate the model better reflects relative costs.

• Using a model that is calibrated with diagnoses selected in the same manner will improve the accuracy of the encounter data risk score.

NEW 2019 RISK ADJUSTMENT MODEL


V23 MODEL HCC ADDITIONSThere were four added HCCs:• HCC56 - Substance Use Disorder, Mild, Except Alcohol and Cannabis• HCC59 - Major Depressive, Bipolar, and Paranoid Disorders• HCC60 - Personality Disorders• HCC138 - Chronic Kidney Disease, Moderate (Stage 3)

One added disease interaction:• gSubstanceAbuse_gPsychiatric_V23 - Substance Use Disorder*Psychiatric• Substance Use Disorder = HCCs 54-56• Psychiatric = HCCs 57-60

And, two HCCs changed the wording of their description.• HCC54 - Substance Use with Psychotic Complications (originally “Drug/Alcohol Psychosis”)• HCC55 - Substance Use Disorder, Moderate/Severe, or Substance Use with Complications

(originally “Drug/Alcohol Dependence”)


EVOLUTION OF THE MODEL SOURCESYear MA Model Year Source Weight

20192017 RAPS 75%2019 EDPS + RAPS IP 25%

2018 2017RAPS 85%EDPS 15%

2017 2017RAPS 75%EDPS 25%

2016 2014RAPS 90%EDPS 10%

20152014

RAPS33%

2013 67%

20142014

RAPS75%

2013 25%2013 2013 RAPS 100%

PACE plans will not have a weight applied to the EDPS dataPayment Condition Count Model not implemented for 2019


ADDITIONAL MODEL FINAL RULES

2018 RxHCC Model will be used in 2019

Updated ESRD dialysis and ESRD functioning graft model

Coding Pattern Adjustment proposed and finalized at 5.90%

Updated frailty factors to determine scores for FIDE-SNPs


FUTURE


Gorman Health Group (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing strategic, operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant, member-centric focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™ (OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization.

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T

E

Jessica SmithSenior Vice President, Risk Adjustment Analytics & Risk [email protected]

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THE EVER-GROWING COMPLEXITY OF RISK SCORE ... - Ciox Health · Risk adjustment is the method used...

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