Friday, September 13, 2019

Opioids: What’s an “Outlier Prescriber”?

Quality Payment Program

Opioids: What’s an “Outlier Prescriber”? Listening Session — September 17

Tuesday, September 17 from 4:30 to 6 pm ET
Register for Medicare Learning Network events.
Are you a physician, nurse practitioner, other advanced practice nurse, or physician assistant who prescribes opioids? CMS wants your input on how best to implement Section 6065 of the SUPPORT Act. 
Signed into law in October 2018, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) outlines national strategies to help address opioid misuse. As part of Section 6065 of the SUPPORT Act, CMS is required to notify opioid prescribers with prescription patterns identified as “outliers” compared to their peers and encourage them to reference established opioid prescribing guidelines. 
The purpose of this listening session is to get feedback on the following topics:
  • Methodology to establish outlier prescriber thresholds
  • Tone and content of feedback reports to clinicians
  • How to best identify a “medical specialty” from the National Provider Identifier framework
  • How to define geographic areas for analysis
  • Recommendations on opioid prescribing guidelines to include with the notification
You are encouraged to review the following materials before the call:
Target Audience: All prescribing clinicians.

Tuesday, May 7, 2019

CMS Confirms New HCCs for PY2020



Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?  

Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

Workshops are approved by the American Medical Association, American Academy of Family Practice for 6 hours of CME and the American Academy of Professional Coders for 7 hours of CEUs.


CMS confirms new HCCs for PY2020 – What should your team be doing now to prepare?

·       EDPS is here to stay – How can you ensure accurate risk scores with the transition away from RAPS?

·       Work Smarter not Harder – Take a deep dive into HCC coding…

Who Should Attend?
Medical Coders and Billers
Providers, Managers and Frontline Staff
CDI Specialists
Executive Leaders
ACO, MSO and IPA Teams
Rural Health Centers
Health Alliance Members
Medicare, Medicaid and Commercial Plans


Please email Kameron Gifford

Friday, May 3, 2019

Certified Coders Needed


ERM Consulting is looking for several HCC Coders and Auditors for remote and on-site positions. 

HCC Coders / Auditors will be primarily responsible for conducting reviews of medical records and validating submitted diagnoses codes to ensure all diagnoses and services are accurately and completely coded. 

HCC Coders / Auditors will also support a variety of other efforts including but not limited to:
  • Identifying errors / opportunities in clinical documentation and coding. 
  • Tracking and trending audit results and preparing reports.
  • Identifying members with "dropped" and / or "suspect" HCC conditions. 
  • Completing supplemental data reports for clients. 
  • Onsite education and training for providers and coders.
  • Facilitating efficient and effective interventions to ensure accurate and complete coding. 

PLEASE NOTE- LOCATION is Fort Lauderdale, Florida for on-site positions. 

What you'll do:
  • Review submitted medical records and identify and code all ICD-10-CM diagnoses that map to a Risk Adjusted HCC and/ or RxHCC ensuring the documentation meets all CMS standard requirements for valid HCC submission.
  • Oversee the outreach/intervention strategy and participates in ongoing development to determine best practices approach with members and providers to assist in improving risk adjustment factors.
  • Work with clients to optimize risk adjustment efforts including communicate opportunities to collaborate and provide updates regarding risk adjustment efforts.
To be considered for this position, you must have:
  • High School Diploma or equivalent
  • Current AAPC CPC (Certified Professional Coder) or AHIMA CCS (Certified Coding Specialist) credential is required.
  • CRC (Certified Risk Coder) Certification within 6 months post hire.
  • 5+ years recent experience in medical record review, diagnosis coding, and/or auditing is required.
  • 8+ years general coding and / or billing experience.
An equivalent combination of education and experience may be substituted for this requirement.

The strongest candidates for this position will also possess:
  • An Associate's degree from an accredited college or university. Experience with Medicare and/or Commercial risk adjustment
  • Experience with Medicare and/or Commercial risk adjustment process is preferred.
  • Experience/understanding of electronic medical & health records is preferred.

Please email resumes to Kameron Gifford -

Tuesday, January 29, 2019

CMS proposes new HCCs for 2020

All NEW 2019 Advanced Risk Management Workshops

Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?  

Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders for CMEs and CEUs.


What is changing for risk adjustment in the V23 model? New ICD-10 codes and HCC categories are here. What should your team be doing now to be successful?

Review the different risk adjustment models and their impact on medical practice management for 2020 and beyond. CMS has proposed new HCCs for PY 2020. What should you be doing now to prepare?

Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?

Take a deep dive into HCC Coding and Documentation.

Review real documentation examples to see what validates, what doesn’t, and why.
Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments. 

Who Should Attend?
Medical Coders and Billers
Providers, Managers and Frontline Staff
CDI Specialists
Executive Leaders
ACO, MSO and IPA Teams
Rural Health Centers
Health Alliance Members
Medicare, Medicaid and Commercial Plans


HOTELS near UNF in Jacksonville for 2/21/2019

Tru by Hilton Jacksonville St. Johns Town Center, 4640 Tropea Way, Jacksonville, FL 32246-8586 - 1.4 miles from University of North Florida

Sheraton Jacksonville Hotel, 10605 Deerwood Park Blvd, Jacksonville, FL 32256-0509 - 2.3 miles from University of North Florida

Hilton Garden Inn Jacksonville JTB / Deerwood Park, 9745 Gate Pkwy N, Jacksonville, FL 32246-8221 - 2.6 miles from University of North Florida

Please email Kameron Gifford

Early Bird Pricing and Group Discounts
Register NOW to save $100 with Early Bird Pricing!
Bring the WHOLE TEAM to save 10% on your order!

Conquer Risk Adjustment and Value Based Payments

Prepare for Victory...

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?
I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.
Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care!
ERM Consulting has developed the industries best training for players on the frontline. Approved by AMA, AAFP and AAPC.

CMS-HCC Premium Package
Prepare your team for success with this deluxe package!
 This package includes all of our best sellers - updated for 2019 with Version 23
         You will receive:
  • 2019 CMS-HCC Mappings
  • 2019 CMS-HCC Quick Coder
  • 2019 CMS-HCC Essentials (HCC RAF and Trump Chart)
  • 2019 CMS-HCC Coding Cards 
Order a set for your entire team!

Saturday, January 19, 2019

Value-Based Insurance Design Model (VBID) CY 2020

The Centers for Medicare & Medicaid Services (CMS) is announcing a broad array of Medicare Advantage (MA) health plan innovations that will be tested in the Value-Based Insurance Design (VBID) model for CY 2020. The VBID model is being tested under the authority of the CMS Center for Medicare and Medicaid Innovation (Innovation Center). The model is designed to reduce Medicare program expenditures, enhance the quality of care for Medicare beneficiaries, including dual-eligible beneficiaries, and improve the coordination and efficiency of health care service delivery. The changes to the VBID Model announced today aim to contribute to the modernization of Medicare Advantage through increasing choice, lowering cost, and improving the quality of care for Medicare beneficiaries.
For CY 2020, and consistent with the requirements of the Bipartisan Budget Act of 2018, eligible Medicare Advantage health plans in all 50 states and territories may apply for the health plan innovations being tested under the VBID model.
In addition to currently eligible plan types, Regional Preferred Provider Organizations (RPPO) and all Special Needs Plan (SNP) types – Chronic Condition SNPs (C-SNP), Dual Eligible SNPs (D-SNP), and Institutional SNPs (I-SNP) – are allowed to apply to the VBID Model for 2020.

For the CY 2020 VBID application period, which is open now through March 1, 2019, eligible Medicare Advantage organizations may apply to test one or more of the following new interventions:

Beginning in CY 2021, the VBID model will also test including the Medicare hospice benefit in Medicare Advantage. CMS will release additional information and guidance on this intervention for interested stakeholders in the coming months through the VBID model website, and through open-door forum type events.
Additionally, in order to be able to sufficiently evaluate the impact on cost and quality of these different approaches, CMS is extending the performance period of the VBID model by an additional three years, through 2024.
Please refer to the VBID CY 2020 Request for Applications for additional detail on 2020 interventions, as well as how to apply at
VBID Model Background
Beginning in January 2017, the VBID model began testing the impact of providing eligible Medicare Advantage plans the flexibility to offer reduced cost sharing or additional supplemental benefits to enrollees with select chronic conditions, focusing on the services that are of highest clinical value to them. The model tested whether providing this flexibility could improve health outcomes and reduce expenditures for Medicare Advantage enrollees.
In 2017, CMS tested the VBID model in seven states, Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee, and allowed testing of VBID interventions for the following disease states: diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories.
In 2018, CMS updated the model to include Alabama, Michigan, and Texas and also allowed for VBID interventions for dementia and rheumatoid arthritis.
For 2019, CMS updated the model to include organizations in fifteen additional states, California, Colorado, Florida, Georgia, Hawaii, Maine, Minnesota, Montana, New Jersey, New Mexico, North Carolina, North Dakota, South Dakota, Virginia, and West Virginia to apply and allowed participants to propose a methodology that either 1) identifies enrollees with different chronic conditions than those previously established by CMS or 2) revises the existing approved CMS chronic condition category to focus on a broader or smaller subset of the existing chronic condition.
The Bipartisan Budget Act of 2018 required that the model be revised to include all 50 states and territories by 2020.  Consistent with these requirements, eligible Medicare Advantage health plans in all 50 states and territories may apply for the health plan innovations being tested under the VBID model for CY 2020.
CY 2017 VBID Evaluation Report
The first year VBID model evaluation report provides a description of the VBID model benefit designs and selected conditions as well as early implementation experiences.
In the first model year (2017), 9 out of 23 eligible Parent Organizations (POs) within 3 of 7 eligible states chose to participate in the model, targeting COPD, CHF, diabetes, and hypertension. Over 96,000 beneficiaries with specified target conditions were eligible for the VBID model; across all participating POs, 61 percent of eligible beneficiaries actually received VBID benefits.  While most 2017 MA plan data were not complete in time for a full impact analysis for this first report, they will be included in future reports. 
Please visit the VBID model website at for the CY 2017 VBID Evaluation Report. 
VBID Model for CY 2020 and Subsequent Years
For CY 2020 and subsequent years, CMS is testing the following health plan innovations in Medicare Advantage through the VBID model. The new interventions described below represent a broad array of value-based approaches to service delivery in MA. 
Value-Based Insurance Design by Condition and/or Socioeconomic Status
Beginning in CY 2020, participating MA plans may propose offering reduced cost-sharing or additional supplemental benefits, including for “non-primarily health related” items or services, for enrollees based on chronic condition, socioeconomic status determined by qualifying for the low-income subsidy and/or having dual-eligible status, or both. Plans may also propose allowing additional “non-primarily health related” supplemental benefits for all enrollees by disease state, regardless of socioeconomic status.
Rewards and Incentives
In order to enable more meaningful rewards and incentives that effectively influence healthy behaviors, CMS is testing the impact of permitting broadened Medicare Advantage and Part D Rewards and Incentives (RI) programs. Specifically, plans may propose RI programs with allowed values that more closely reflect the expected benefit of the health related service or activity, up to an annual limit, to better promote improved health, prevent injuries and illness, and promote the efficient use of health care resources.
Participating MA plans that offer a Prescription Drug Plan (MA-PDs) may also offer RI programs for enrollees who take covered Part D prescription drugs and who participate in disease state management programs, engage in medication therapy management with pharmacists or providers, receive preventive health services, and actively engage in understanding their medications, including clinically-equivalent alternatives that may be more cost-accessible.
Telehealth Networks
Through this intervention, CMS is testing how different service delivery innovations in telehealth can be used to both augment and complement an MA plan’s current network of providers, as well as how access to telehealth services may appropriately allow MA plans to expand their service area to currently underserved counties where current MA network adequacy requirements could not be met without the use of telehealth.
Where deemed appropriate by CMS, MA plans may propose using telehealth services in lieu of in-person visits to meet network adequacy requirements. Organizations must ensure that enrollee choice is preserved and that enrollee access to an in-person visit, if that is the enrollee’s preference and choice, is maintained. CMS expects that this will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices. 
The two different approaches CMS is testing are: 1. how plans can use telehealth services to complement and augment their current network of providers, including proposals where telehealth networks may comprise up to one-third of the required in-network providers for a specialty or specialties; and 2. how the use of telehealth services allows MAOs to offer a broadened service area, including counties where the choice of an MA plan may not have previously been able to be offered.
Wellness and Health Care Planning
Organizations participating in VBID, working with their network of providers, will be required to offer enrollees improved, timely access to Wellness and Health Care Planning (WHP), including advance care planning. Each MA organization applying for the VBID model must submit its proposed approach to WHP for their enrollees as part of the application.
Through the VBID model, CMS will evaluate the impact on quality and cost of best practices for performing WHP in the Medicare Advantage population.

Saturday, December 15, 2018

Is your organization currently taking on risk or participating in value-based payment models?

If so, we can help! 

ERM Consulting will work with your team to develop an internal risk adjustment program. 

Services Included:
  • Remote Auditing and Monitoring - Review of 25 encounters per provider, per month, with detailed monthly reports to track error trends and validation rates. 
  • Development of Custom Education - Custom education for providers and coders, every quarter, to reinforce positive changes and educate on new opportunities. 
  • Onsite Meetings (One week on-site per Quarter) - 1:1 meetings with providers, coders and leadership to review current audit results and discuss opportunities for improvement. 
  • Oversight and Guidance - ERM will provide oversight and guidance to assist with the development of development of internal team and processes needed to manage new payment models. 

Strategic Considerations:
  1. Who will be part of the team and what role will they play? 
  2. What new processes need to be added or adjusted?
  3. How will the team communicate and measure success?

Who is On-boarding, Training and Managing your Coders?

ERM also offers remote on-boarding, training and management of coders and billing teams. 

Contract during the month of December and receive a 25% Discount – on all HCC Coding Tools by ERM – visit our online store at to see a complete list.