Saturday, February 15, 2020

Primary Care First Model

Is your organization participating?
Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. Primary Care First is based on the underlying principles of the existing CPC+ model design: prioritizing the doctor-patient relationship; enhancing care for patients with complex chronic needs and high need, seriously ill patients, reducing administrative burden, and focusing financial rewards on improved health outcomes. 

Primary Care First Model Options will be offered in 26 regions for a 2021 start date: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).




The PCF model includes professional population-based payments and flat primary care visit fees to help practices improve access to care and transition from FFS to population-based payments. 


If your practice is located in one of the 26 regions and has at least 800 FFS Medicare patients, you should strongly consider particpating in the PCF model.  

  • Primary Care First practices may also participate in ACOs in the Medicare Shared Savings Program (Shared Savings Program).
  • Primary Care First practices may not participate in the Next Generation ACO Model or the Comprehensive End Stage Renal Disease (ESRD) Care Model. 

If you have any questions or need additional guidance navigating the Primary Care First Model, ERM Consulting can help!


Todd Gifford, MBA, CRC 
772-267-8156

Kameron Gifford, CPC
772-267-9453


Tuesday, February 4, 2020

2020 HCC Quick Coders



2020 HCC Quick Coders are ready for shipping!



Completely updated for 2020 - Version 24

This 40 page guide contains everything you need to calculate a risk score in one place!

Includes 200+ of the most common HCC codes in the Medicare (CMS-HCC) model.

This guide was designed for providers, with codes sorted alphabetically rather than by code.


Includes:
  • List of ICD-10 Guidelines
  • 270 ICD-10 Codes (Rx and HCCs)
  • Quality CPT II codes for MIPS / MACRA
  • 2020 CMS-HCC Factors (includes demographic, disease and interaction)
  • 2020 Trump Chart

Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to orders@ermconsultinginc.com after purchase.




Visit https://erm.ecwid.com/ to see learn more and place your order.


Sunday, February 2, 2020

Advance Notice of Changes for Calendar Year (CY) 2021

CMS published the Advance Notice on January 6th 2020


NOTE TO: Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and Other Interested Parties

SUBJECT: Advance Notice of Methodological Changes for Calendar Year (CY) 2021 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies – Part I, CMS-HCC Risk Adjustment Model

Medicare Advantage has been successful in providing Medicare beneficiaries with options so
that they can choose the healthcare that best fits their individual health needs. The Medicare
Advantage program demonstrates bringing the value of private sector innovation and creativity
to a government program, and CMS is committed to continuing to strengthen Medicare
Advantage by promoting greater innovation, transparency, flexibility, and program
simplification.

A key element in the success of Medicare Advantage is ensuring that payments to plans reflect
the relative risk of the people who enroll. A critical tool that CMS uses to accomplish that goal is
the risk adjustment models that adjust payments based on the characteristics and health
conditions of each plan’s enrollees.

Summary of Proposal for CY 2021 


For CY 2021 CMS is proposing to continue using the CMS-HCC model that was implemented in CY 2020 (i.e., 2020 CMS-HCC model). CMS is proposing to continue using the 2020 CMSHCC model to calculate encounter data-based scores and the 2017 CMS-HCC model to calculate RAPS-based scores. Under this proposal, 75% of the risk score would be calculated with the 2020 CMS-HCC model and 25% of the risk score would be calculated with the 2017 CMS-HCC model.


Proposal for 2021 and Three-year Phase-in 2019 - 2022 


The 21st Century Cures Act requires that any changes to risk adjusted payments under section 1853(a)(1)(C)(i) resulting from the implementation of section 1853(a)(1)(I) must be phased in over a three-year period, beginning with 2019, with such changes being fully implemented for 2022 and subsequent years. The statute thus requires a three-year phase-in over a four-year period. In the CY 2019 Advance Notice, we explained how we interpreted the statute’s direction to mean that the proposed changes to the risk adjustment model under section 1853(a)(1)(C)(i) could be implemented in 2019 without all the required provisions from section 1853(a)(1)(I), and could be further modified and implemented fully consistent with provisions from section

1853(a)(1)(I) for 2020. The model finalized for 2020 included modifications to meet all of the provisions from section 1853(a)(1)(I), and will be phased in over three years such that 100% of risk adjusted payments to MA organizations and certain demonstrations for 2022 are based on a risk adjustment model that complies with the statutory requirements in section 1853(a)(1)(I) of the Act. In order to phase in a model that meets the statutory requirements, risk score calculation for payment to MA organizations and certain demonstrations during the phase-in period reflects the transtion as follows:

For Payment Year 2019, we are calculating risk scores using the sum of:

  • 25% of the risk score calculated with the 2019 CMS-HCC model and 
  • 75% of the risk score calculated with the 2017 CMS-HCC model. 

For Payment Year 2020, we are calculating risk scores using the sum of:

  • 50% of the risk score calculated with the 2020 CMS-HCC model and 
  • 50% of the risk score calculated with the 2017 CMS-HCC model. 


For Payment Year 2021, we propose to continue the phase in of the changes to the model by calculating risk scores using the sum of:


  • 75% of the risk score calculated with the 2020 CMS-HCC model and 
  • 25% of the risk score calculated with the 2017 CMS-HCC model. 


For PACE organizations, we propose to continue to use the 2017 CMS-HCC model to calculate risk scores in CY 2021, as described in the CY 2020 Advance Notice Part II and CY 2020 Rate Announcement.


Encounter Data as a Diagnosis Source for 2021 


For CY 2020, CMS is calculating risk scores for payment to MA organizations and certain demonstrations by adding 50% of the risk score calculated using risk adjustment eligible diagnoses identified from encounter data, FFS claims, and RAPS inpatient records with 50% of the risk score calculated using risk adjustment eligible diagnoses identified from RAPS data and FFS claims.

For CY 2021, CMS proposes to calculate risk scores for payment to MA organizations and certain demonstrations by adding 75% of the risk score calculated using risk adjustment eligible diagnoses identified from encounter data, FFS claims, and RAPS inpatient records with 25% of the risk score calculated with risk adjustment eligible diagnoses identified from all RAPS data and FFS claims.

Specifically, we propose to calculate the encounter data-based risk scores as follows:


  • With the 2020 CMS-HCC model, 
  • Using risk adjustment eligible diagnoses from encounter data, FFS claims, and RAPS inpatient records. 


RAPS-based risk scores would be calculated as follows:


  • With the 2017 CMS-HCC model, 
  • Using risk adjustment eligible diagnoses from RAPS data and FFS claims


Thus, as proposed, encounter data-based risk scores would only be calculated with the 2020 CMS-HCC model.

For PACE organizations for CY 2021, we propose to continue the same method of calculating risk scores that we have been using since CY 2015, which is to pool risk adjustment-eligible diagnoses from the following sources to calculate a single risk score (with no weighting): (1) encounter data, (2) RAPS data, and (3) FFS claims



Read the entire advance notice here



The Final Rate Announcement

For CY 2021, CMS will announce the Medicare Advantage capitation rates and final payment
policies no later than Monday, April 6, 2020, in accordance with the timetable established in
section 1853(b)(2), as amended by the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (MMA) (Pub. L. 108-173) and the Securing Fairness in Regulatory
Timing Act of 2015 (SFRTA) (Pub. L. 114-106).


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