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

Doctor Sentenced in Health Care Fraud Obstruction Case

U.S. Attorney’s OfficeJuly 22, 2013
  • Southern District of Illinois(618) 628-3700
Dr. Mahmoud Yassin, 61, of Robinson, Illinois, was sentenced in federal district court in Benton for obstructing a criminal health care fraud investigator, the United States Attorney for the Southern District of Illinois, Stephen R. Wigginton, announced today. Dr. Yassin was sentenced to serve three years of probation, a fine of $10,000, a special assessment of $100, and he was ordered to pay restitution to BCBS of Illinois in the amount of $19,615.17. As a condition of probation, Dr. Yassin must also serve 30 days in prison.
The felony obstruction occurred on March 2, 2012, when a FBI agent, having served a subpoena for patient records on Dr. Yassin, was given a patient progress note that had been altered by the doctor to show an in-office examination previously claimed to an insurance carrier, but which had not taken place.
In a civil settlement with the United States Attorney’s Office regarding false claims to Medicare, Dr. Yassin paid double damages in the amount of $87,348.64. The restitution and civil false claims settlement were based on claims for in person office visits in which the patient either failed to show up for an appointment or only was spoken to by telephone.
The case was investigated by agents of the Federal Bureau of Investigation, the Department of Health and Human Services-Office of Inspector General, the Drug Enforcement Administration, and the Illinois State Police Medicaid Fraud Control Bureau. The case is assigned to Assistant United States Attorney Michael J. Quinley.

Hospitals May Soon Be Reaching For The Stars - Kaiser Health News

JUL 18, 2013
Star wars may be coming to a hospital near you.
Medicare is considering assigning stars or some other easily understood symbol to hospitals so patients can more easily compare the quality of care at various institutions. The ratings would appear on Medicare’s Hospital Compare website and be based on many of the 100 quality measures the agency already publishes.
The proposal comes as Medicare confronts a paradox: Although the number of ways to measure hospital performance is increasing, those factors are becoming harder for patients to digest. Hospital Compare publishes a wide variety of details about medical centers, including death rates, patient views about how well doctors communicated, infection rates for colon surgery and hysterectomies, emergency room efficiency and overuse of CT scans.
In its proposed rules for hospitals in the fiscal year starting Oct. 1, the Centers for Medicare & Medicaid Services asked for ideas about "how we may better display this information on the Hospital Compare Web site. One option we have considered is aggregating measures in a graphical display, such as star ratings."
Private groups such as Consumer Reports, the Leapfrog Group and US News and World Report already issue hospital guides that boil down the disparate Medicare scores -- along with their own proprietary formulas -- to come up with numeric scores, letter grades or rankings.
But even before it's formally proposed, the possibility of the government rating hospitals based on a star system is receiving less than heavenly reviews. In a letter to Medicare, the Association of American Medical Colleges said it "strongly opposes the use of a star rating system, which may make inappropriate distinctions for hospitals whose performance is not statistically different. A star rating system can also exaggerate minor performance differences on measures."
In a statement, Medicare defended the idea. "Visual cues can be an important way to help patients understand how their hospital measures up to others," it said, adding that the government is interested in hearing from people about "user-friendly, creative designs for a rating system to help patients get information so they can take an active role in their care."
Peter Slavin, president of Massachusetts General Hospital, said making medical care standards more comprehensible is a worthwhile pursuit, but a good hospital ranking system would need to be based on more sophisticated underlying data than what’s now available.
"The quality information we're now using in health care is pretty crude and needs to get a lot better," Slavin said.
Much of that data is derived from the bills hospitals submit to Medicare, which he said is "a lot like judging the quality of a restaurant from the checks they give to their customers."
Slavin questioned whether star ratings would be useful for patients seeking specific services, such as a lung transplant, which Medicare does not evaluate.
"At some point if you oversimplify things, you're not providing people with information that is all that meaningful or helpful," he said.
Robert Berenson, a health policy researcher at the Urban Institute in Washington, D.C., also wondered whether there is enough solid information about medical care quality available to make star-rating system effective.
"I recognize the appeal of making things easy for consumers by giving stars, but I don't think the data is robust enough and valid enough," Berenson said. "There are important gaps in what's measurable. What gets considered important is what we can measure, not the other way around."
But Tanya Alteras, deputy director of the advocacy group Consumer-Purchaser Disclosure Project, was more enthusiastic about a star system. "If it's tested with consumers and shown to be useful we are definitely in favor it," she said.
Medicare already uses a five-star system to rate the private Medicare Advantage health insurance plans. A quarter of U.S. seniors get their insurance from these private insurers, which Medicare helps pay for, instead of through traditional Medicare, which pays hospitals, doctors and other providers directly for medical services. Those stars carry extra gravity because Medicare gives financial bonuses to high-performing plans.
But applying such a system to hospital quality could be challenging. Private groups have come up with differing judgments on the same hospitals. For instance, hospitals given an "A" in patient safety by Leapfrog for patient safety can end up at the bottom of Consumer Reports’ rankings because of differences in their analyses.
And even Medicare's current evaluations of hospital care and services don't always lead to consistent overall conclusions. For instance, Medicare rates Beth Israel Deaconess Medical Center in Boston as above average nationally in keeping heart attack, heart failure and pneumonia patients from dying, but below average in readmissions and the frequency of collapsed lungs and accidental cuts and tears during treatments.
Beth Israel declined comment for this story.
Also, Medicare's current quality evaluations using statistical tests end up concluding most hospitals are indistinguishable from one another on major performance measures such as death rates. On Hospital Compare, 9 out of 10 hospitals' mortality rates are described as "average." That kind of narrow range doesn't lend itself to a star system, said Leapfrog executive director Leah Binder.
"If their plan is to give the same number of stars to all the hospitals, at best it will be boring," Binder said. "At worst it will be misleading."

Hospitals May Soon Be Reaching For The Stars - Kaiser Health News

Florida Association of Accountable Care Organizations (FLAACOs) Holds First Member Meeting

Jacksonville, FL, July 21, 2013 --( The founding members of the Florida Association of ACOs (FLAACOs) recently held its first official all members meeting in Orlando at an event sponsored by eClinicalWorks. According to Nicole Bradberry, the organization’s chief executive officer, the meeting gave the ACOs a chance to share best practices. “We’re all visionaries in creating more coordinated patient care that leads to higher quality and lower costs,” she said. “Having the opportunity to share experiences was invaluable to all who attended.”

Kelly Conroy, the executive director of both the Palm Beach ACO and the South Florida ACO, echoed those sentiments saying, “ACOs are setting the tone for health care in the future. Delivering the right care to the right patient at the right time will be the standard as we all work together with the help of FLAACOs to find the best and most efficient methods in all areas of medicine.”

In addition to presentations from eClinicalWorks, the meeting included welcome and wrap-up by Nicole Bradberry and talks from Brenda Radke with Brevard Physicians Network, about patient engagement; Gino Tenace, chief strategy officer for MedSolutions (Greater Nashville Area), who addressed medical costs; Kelly Conroy, PBACO, who spoke about shared savings; Sheila Fuse, Primary Partners, who talked about gPro Reporting; and Mike Segal, a partner and health law attorney with Broad and Cassel, regarding waivers.

The founding members of the organization include: Orange Accountable Care Jacksonville, Northeast Florida), American Health Alliance (Ocala & The Villages, Central Florida), Medical Practitioners for Affordable Care (Melbourne, Brevard County), Nature Coast ACO (Beverly Hills, FL, Citrus County), Collaborative Care of Florida (Orlando Area), Physicians Collaborative Trust ACO (Maitland, Central Florida), ProCare Med (Fort Myers, Southwest Florida). Palm Beach Accountable Care Organization (Palm Beach, FL Area), South Florida Accountable Care Organization (Miami-Dade and Broward Counties) Primary Partners (Clermont, Lake County), Primary Partners ACIP (Clermont, Lake County), BAROMA Health Partners (OTC, BRMA) (Miami, FL), and Diagnostic Clinic Walgreens Well Network (Tampa-based, Florida Statewide).

The Centers for Medicare & Medicaid Services paved the way for ACOs with the Medicare Shared Savings Program (MSSP). As of May 2013, 220 MSSP ACOs and 32 32 Pioneer ACOs were serving 4.1 million assigned beneficiaries in 47 states, plus Washington, D.C. and Puerto Rico.

“FLAACOs will create a community to provide a voice for the ACO marketplace and its participating physicians,” said Bradberry, who also serves as president Orange Health Solutions, which fully manages two ACOs in North and Central Florida and provides services to others. “Our goal, with this association, is to provide advocacy and support to all Florida ACOs so they can become the health-care models of the future.”

Press Contact Information:
Orange Health Solutions
Kristi Stovall, VP, Marketing & Brand Management
Office: 904-201-9485