Monday, July 22, 2013

MRA Education: 3 Strategic Aims for Medicare Advantage

With EDPS, Coding and Encounter Reporting are the two critical components of risk adjustment that plans must address and master if they are to obtain the revenue they deserve and require to ensure their continued viability and success.
Small differences in encounter acceptance have a large impact on a plan’s revenue.
90% acceptance = $244  95% acceptance=$258   99% acceptance = $269  - A difference of $25MM

If that is not enough motivation, consider the 2013 OIG Work Plan
Encounter Data—CMS Oversight of Data Integrity (New) –
We will review the extent to which MA encounter data reflecting the items and services provided to MA plan enrollees are complete, consistent, and verified for accuracy by CMS. In 2012, MA encounter data reporting requirements will expand from an abbreviated set of primarily diagnosis data to a more comprehensive set of data. (One Time Notification, Pub. 100-20, CR 7562.) Prior CMS and OIG audits have indicated vulnerabilities in the accuracy of risk adjustment data reporting by MA organizations. (OEI; 00-00-00000; expected issue date: FY 2014, new start)

Accurate Funding
Complete and accurate medical records at the point of care provides better outcomes, improves the experience of care, reduces costs and adds value to all stake holders. How much money did you spend on chart reviews for “missed” diagnosis codes?  Consider the following example:

RISK Score
Baseline Revenue
Potential Increase
Potential PMPM revenue 100% baseline
Present RAF

Scenario 1

Annual Attestation
MA Plans must certify that risk adjustment data is accurate, complete, and truthful (based on best knowledge, information and belief) (42 CFR 422.504 (I))

This creates a duty to, at a minimum, “put in place an information collection and reporting system reasonably designed to yield accurate information,” including ordinarily conducting “sample audits and spot checks…to verify whether the system is yielding accurate information

Kameron Gifford, CPC

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