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Risk Adjustment User Group - PowerPoint PPT Presentation

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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. User Group Process. All attendees must pre-register It is only necessary to register once

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Risk Adjustment User Group

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Presentation Transcript
welcome to the april user group
Welcome to the AprilUser Group
  • Introduction
  • Payment Process
  • Data Validation
  • Operations Update
  • Questions and Answers
  • Closing

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
  • 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.



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:
    • Analyst@askriskadjustment.com for Payment Operations
    • Mary.guy@cms.hhs.gov for Data Validation
payment process
  • Post transition
    • 81% resolved in January 2010
    • 91% resolved in February 2010
    • 60% resolved in March 2010
payment process1
  • For 2011, CMS will not implement new risk adjustment models for:
    • CMS-HCC
  • 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

Question –

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

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 validation1
  • 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 validation2
  • 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 validation3
  • 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 validation4

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 validation5

RADV Appeals

  • Two Pronged Process for RADV Appeals
    • Appeal medical record review determinations
    • Appeal payment error calculation
data validation6

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 validation7

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 validation8
  • 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
  • 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
  • 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
  • Next User Group Meeting
  • May 19, 2010
  • New participants can register to attend the UG session from the www.TARSC.info
  • Sean Creighton (Director, Division of Risk Adjustment & Payment Policy)


  • Henry Thomas (Training, Project Officer)


  • Louis Johnson (FERAS,GTL)


  • Chanda.McNeal (RAS Payment)


  • Payment Research


  • Jennifer Harlow (RADV)


  • Lateefah Hughes (RADV)


  • Mary Guy (RADV)


  • LTC - www.tarsc.info
  • CSSC - www.csscoperations.com