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Risk Adjustment User Group. April 2010. Welcome to the April User Group. Introduction Payment Process Data Validation Operations Update Questions and Answers Closing. Introduction. INTRODUCTION. INTRODUCTION. User Group Process. All attendees must pre-register

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Welcome to the april user group
Welcome to the AprilUser Group

  • Introduction

  • Payment Process

  • Data Validation

  • Operations Update

  • Questions and Answers

  • Closing


Introduction
Introduction

INTRODUCTION


Introduction1
INTRODUCTION

User Group Process

  • All attendees must pre-register

  • It is only necessary to register once

  • Retain unique PIN for all sessions

  • Session will last for one hour

  • Session slides will be available by the Tuesday before the session

  • Panel will answer questions during the Q&A portion of the session


Introduction2
INTRODUCTION

  • The 2010 monthly Risk Adjustment User Group dates are posted on the CSSC Operations website.

  • Please continue to review the website for updates to this information.

www.csscoperations.com/new/usergroup/usergroupinfo.html


Introduction3
INTRODUCTION

Q&A Resources

  • User Group Calls cover 2 risk adjustment areas: Payment Operations and Data Validation.

  • On the calls, subject matter experts are available from each area to answer questions.

  • To submit questions outside of User Group:

    • [email protected] for Payment Operations

    • [email protected] for Data Validation


Payment process
Payment Process

PAYMENT PROCESS


Payment process1
PAYMENT PROCESS

  • Post transition

    • 81% resolved in January 2010

    • 91% resolved in February 2010

    • 60% resolved in March 2010


Payment process2
PAYMENT PROCESS

  • For 2011, CMS will not implement new risk adjustment models for:

    • CMS-HCC

    • CMS-HCC ESRD

  • For 2011, risk adjustment factors

    • CMS-HCC Model refer to the 2009 Rate Announcement (published in April 2008)

    • CMS-HCC ESRD Model refer to the 2008 Rate Announcement (published in April 2007).

      For more information view the 2011 Announcement at http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Announcement2011.pdf


Payment process faq
PAYMENT PROCESSFAQ

Question –

Why would a beneficiary enrolled in a plan for more than 12 months have an RA Factor Type Code of “E”?


Data validation
Data Validation

DATA VALIDATION


Data validation1
DATA VALIDATION

  • Status Update

    • CY 2007 Targeted Sample

      • Medical records submitted

      • Medical record review next step

    • CY 2008 National Sample

      • Medical records submitted

      • Medical record review next step

    • CY 2008 Contract-Level Sample

      • Expect request to go out this summer


Data validation2
DATA VALIDATION

  • CY 2007 Targeted and CY 2008 National Sample-specific reports

    • Two types of reports

      • Technical Assistance Report

      • Medical Record Receipt Report

    • Expect to receive reports shortly

    • It is very important that MA organizations review and report any issues to the Intake Medical Record Review Contractor (IMRRC) as directed


Data validation3
DATA VALIDATION

  • Technical Assistance Report

    • Provided to help with addressing potential submission issues which may impact medical record review findings for your contract

    • Distributed via email to confirmed contacts for a contract: Medicare Compliance Officer, primary and secondary contacts  

    • Examples of some potential issues

      • Coversheet does not correspond with documents submitted

      • Pages or margins of medical record are cut off

      • Portions of text are obliterated

    • To respond to Technical Assistance Report, refer to instructions that appear on the report and accompanying email message. 

    • Do not send any medical record documentation directly to CMS. Send only to the IMRRC according to instructions for your audit


Data validation4
DATA VALIDATION

  • Medical Record Receipt Report

    • Identifies documentation received by category by the IMRRC; categories are:

    • Medical Record Only - We received the coversheet with an attached medical record.

    • Coversheet Not Received - We did not receive the coversheet.

    • No Medical Record or CMS-Generated Attestation - We received the coversheet with no attached medical record or CMS-generated attestation.

    • Medical Record and CMS-Generated Attestation - We received the coversheet with an attached CMS-generated attestation and medical record.


Data validation5
DATA VALIDATION

RADV Appeals

  • RADV Appeals Regulation

    • Medicare Advantage and Prescription Drug Plans Part C & D Policy & Technical Rule (CMS-4085-F)

    • http://www.federalregister.gov/inspection.aspx#special

    • Final Regulation on display: April 6, 2010  

    • Expected publication date:  April 15, 2010


Data validation6
DATA VALIDATION

RADV Appeals

  • Two Pronged Process for RADV Appeals

    • Appeal medical record review determinations

    • Appeal payment error calculation


Data validation7
DATA VALIDATION

Medical Record Review Appeals

  • MA organizations may appeal medical record review determinations from IVC/audit report of findings

    • CMS will specify which HCCs are eligible for appeal

  • MA organization appeal to CMS designated hearing officer

    • Appeal-level medical record review conducted

    • Decision made by hearing officer

    • 2nd audit report of findings issued

  • Discretionary CMS Administrator Review


Data validation8
DATA VALIDATION

Payment Error Calculation Appeal

  • Payment Error Calculation Appeals Eligibility Criteria

    • MA organizations may choose to appeal CMS’ calculation of RADV, contract-level error-estimate

    • MA organizations must adhere to established RADV audit requirements

    • CMS’ payment error calculation methodology is not eligible for appeal

  • Three stage process:

    • Reconsideration

    • Hearing

    • Discretionary Administrator Review


Data validation9
DATA VALIDATION

  • RADV Targeted 2007 Contract-Level Sample

    • CMS will be providing appeals information

  • RADV CY 2008 Contract-Level Sample

    • Training will be held for selected MAOs

      • In-person at CMS, and

      • Via Webinar


Operations updates
Operations updates

OPERATIONS UPDATES


Operations
OPERATIONS

  • Submission Information:

    • Same submitter may transmit for several MA organizations.

    • Multiple batches are allowed per Hxxxx number.

    • More than one detail record (CCC) is allowed per HIC number.

    • NPI (National Provider Identifier) is not required for risk adjustment.

    • Once a cluster is submitted and stored, it is not necessary/required to resubmit.


Cssc faq s
CSSC FAQ’s

  • Q. Can I delete all the errors I received in my file, to lower my error percentage rate?

  • A. No - claims that receive an error are not stored. In order for an error to be deleted it must be stored in the system.

  • Q. Why is risk adjustment important to physicians and providers?

  • A. The risk adjustment model relies on the ICD-9-CM diagnosis codes to prospectively reimburse MA organizations based on the health status of their enrolled beneficiaries. Physicians and providers must focus attention on complete and accurate diagnosis reporting according to the official ICD-9-CM coding guidelines.


Technical assistance updates
Technical Assistance updates

TECHNICAL ASSISTANCE

UPDATES


Technical assistance updates1
TECHNICAL ASSISTANCE UPDATES

  • Next User Group Meeting

  • May 19, 2010

  • New participants can register to attend the UG session from the www.TARSC.info


Questions answers
Questions & Answers

QUESTIONS & ANSWERS


Closing
Closing

CLOSING


Resources
RESOURCES

  • Sean Creighton (Director, Division of Risk Adjustment & Payment Policy)

    [email protected]

  • Henry Thomas (Training, Project Officer)

    [email protected]

  • Louis Johnson (FERAS,GTL)

    [email protected]

  • Chanda.McNeal (RAS Payment)

    [email protected]

  • Payment Research

    [email protected]

  • Jennifer Harlow (RADV)

    [email protected]

  • Lateefah Hughes (RADV)

    [email protected]

  • Mary Guy (RADV)

    [email protected]

  • LTC - www.tarsc.info

  • CSSC - www.csscoperations.com


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