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Risk Adjustment User Group

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  1. Risk Adjustment User Group June 2008

  2. Welcome to the JuneUser Group • Introduction • Payment Process • Operations Update • Data Validation • Technical Assistance Update • Questions and Answers • Closing

  3. INTRODUCTION

  4. 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

  5. INTRODUCTION • The 2008 monthly Risk Adjustment User Group Q & A and Notes documents are posted at the CSSC Operations website. • Please continue to review the website for updates to this information. www.csscoperations.com/new/usergroup/usergroupinfo.html

  6. PAYMENT PROCESS

  7. PAYMENT PROCESS Plan Payment Report (PPR) • Also known as the “Payment Letter” • The Automated Plan Payment System (APPS) produces the PPR • Itemizes final monthly payments to MCO, as part of the month-end process

  8. PAYMENT PROCESS • Includes: Summarized Parts A/B and D payments, Adjustments, NMEC, COB, User Fees (Jan-Sep each year), Premium Settlement Information, monthly LIS Amounts, Identifies members with low-income cost sharing payment components, etc. • For further details review: Plan Communications User Guide, Ver 3.1 (April 18, 2008), Appendices, Section I, pages I-39 through I-43

  9. PAYMENT PROCESS Budget Neutrality Factor • Budget Neutrality Factor is calculated as the difference between payments under 100 % of the risk adjustment method (i.e., under the CMS-HCC Model) versus payment under 100 % of the demographic only method. • Phase Out of Budget Neutrality

  10. DATA VALIDATION

  11. DATA VALIDATION • Calendar Year 2007 • Calendar Year 2006 • Calendar Year 2005

  12. OPERATIONS UPDATES

  13. OPERATIONS • QUESTION: The Medicare Advantage (MA) plan has a death certificate, but the provider continues to submit the encounter with the date of discharge after the date of death. How do we resolve this issue? • ANSWER: If the date of discharge is after the date of death, then RAPS will reject the claim. Normally, MA plans may not change the date of discharge on an inpatient claim. However, in the circumstance that a hospital refuses to change the discharge date or through date to the date of death, then the MA may make this change. Any other changes to the from and through dates must come from the hospital only (Reference: February, 2005 User Group Q&A, Data Submission, Question #4).

  14. TECHNICAL ASSISTANCE UPDATES

  15. TECHNICAL ASSISTANCE UPDATES 2008 Monthly Technical Assistance Sessions • Risk Adjustment Session • June 25th • Enrollment & Payment Session • July 30th Register today at www.tarsc.info

  16. TECHNICAL ASSISTANCE UPDATES Next User Group Session July 16, 2008 Sessions held on Wednesdays at 1:30 pm Eastern Standard Time

  17. REGIONAL TECHNICAL ASSISTANCE SESSIONS Registration Is Now Open! CHICAGO, IL August 11 – August 14 LAS VEGAS, NV August 26 – August 29 NEW ORLEANS, LA September 9 – September 10

  18. TECHNICAL ASSISTANCE UPDATES *For detailed information and to register online log on to www.tarsc.info Technical Assistance Registration Service Center

  19. QUESTIONS & ANSWERS

  20. CLOSING

  21. RESOURCES • Sean Creighton (Director, Division Risk Adjustment Operations) sean.creighton@cms.hhs.gov • Henry Thomas (Training, Project Officer) henry.thomas@cms.hhs.gov • Lateefah Hughes (Data Validation, Team Lead) lateefah.hughes@cms.hhs.gov • Louis Johnson (FERAS,GTL) louis.johnson@cms.hhs.gov • Chanda McNeal (Payment Issues) raf_payment_questions@cms.hhs.gov • LTC www.tarsc.info • CSSC www.csscoperations.com