Optum Advisory Services Strategies to improve accuracy and completeness of risk adjustment

Transcription

1 Payers and providers Optum Advisory Services Strategies to improve accuracy and completeness of risk adjustment IMPROVE CARE QUALITY MANAGE RISK REDUCE COST ADVANCE INFRASTRUCTURE GROW MARKET SHARE Growing compliance requirements and risk exposure As Medicare Advantage leaders prepare strategies for success in 2018 and beyond, effective compliance strategies will continue to distinguish top performers. CMS intends to expand the Medicare Advantage Risk Adjustment Data Validation (RADV) Program to yearly reviews of all plans (currently 5 percent of total) Error rate extrapolation expected to continue RADVs to include both comprehensive and Hierarchical Condition Categories (HCC)-specific audits CMS indicated plan to recover overpayments Growing Medicare RADV audits and risks With growing oversight, requirements and exposure to audits, it is more important than ever for leaders to understand their organization s risk adjustment portfolio and impacts. The costs of inaction are significant to many organizations annual plan audits CMS proposed annual plan audits Key questions leaders are asking themselves today: How do we perform on RADV vs. industry and peers? How can we benchmark our overall risk adjustment performance? What are opportunities to improve financial risk through improved coding accuracy? Are we effectively submitting data? Which regulation changes will impact us most today and tomorrow?

2 Building successful programs to improve risk adjustment accuracy and completeness can be a challenge for any organization. Patient experiences, care quality and millions of dollars can be abandoned by ineffective programs. Beyond RADV concerns, organizations should consider all that they are doing to capture and submit accurate and complete diagnosis data for each patient. Putting effective processes and tools in place with an effective risk adjustment strategy can improve quality of care, reduce cost and increase provider and member satisfaction. Many options exist, so how do you know which are the best for your organization and your beneficiaries? Keys to driving risk adjustment success When many organizations think of risk adjustment, they most often consider traditional program structures. These include retrospective programs, led by chart review, and prospective programs, led by physician education and data at the point of care. Organizations should also consider member engagement, compliance, submissions, data controls and financial reporting when rounding out their strategies. Many varieties of these programs exist for improving the accuracy of risk adjustment factor (RAF) scores and payment impacts. Each component below should be taken into consideration to truly have an effective and integrated strategy. Errors and omissions in the diagnosis data submitted to CMS by Medicare Advantage Organizations (MAO) are the drivers of the 9.5 percent improper payment rate in Medicare Part C. Currently, CMS audits 30 MAO contracts (approximately 5 percent) per payment year. CMS is considering to increase the number of MAO contracts that are subject to some type of RADV audit for each payment year. Our ultimate goal is to have all MAO contracts subject to either a comprehensive or condition-specific RADV audit for each payment year. CMS RAC RFI, November 2015 Prospective programs Retrospective programs Member engagement Compliance Submissions Financial projections and reporting PROVIDER MEDICAL RECORD DIAGNOSIS ON CLAIM PROVIDER SYSTEMS HEALTH PLAN CMS Programs that are most effective often address risk adjustment as an integrated part of other patient and provider engagement programs, such as the Medicare Advantage Quality programs. The most successful risk adjustment and compliance programs focus on accurate submissions, documentation, coding and education. While there are opportunities to capture omissions or errors in the submission process, the largest improvements start with understanding any root causes of documentation gaps, correcting them in advance and improving them going forward. Another important factor is placing the right data at the point of care for the providers to best assess and document the complete set of accurate and complete diagnosis data when seeing the patient. By working to improve all of these areas, leaders can ensure proper payments, better efficiencies and improved health care. When risk adjustment strategies are fully integrated, payers, providers and members can all collectively benefit from: Revenue accuracy Cost reductions Improved care Improved outcomes Reduced financial risk from audits Improved clinical workflow The Medicare Parts C and D Recovery Audit Program was created to identify and correct past improper payments to Medicare providers, and implement procedures to help the Centers for Medicare and Medicaid Services (CMS), Medicare carriers, fiscal intermediaries and Medicare Administrative Contractors (MACs) implement actions that will prevent future improper payments. Communication about audit results and trends leads to continuous process improvement and more accurate payments, and helps plan sponsors correct issues in a timely manner. cms.gov Page 2

3 Organizations can proactively address these requirements and risks by: Benchmarking their results compared to their marketplace Understanding the revenue impact of risk-based contracts and the specific requirements Assessing financial impacts of risk adjustment accuracy improvements and completeness for member populations and chronic conditions Developing an integrated strategy customized to the unique needs and capabilities of their organization to target priorities using integrated approaches Executing programs with expertise required to deliver desired short- and longterm improvements Helping leaders to identify gaps and improve care quality Optum Advisory Services works across the entire health system to identify gaps and address opportunities for improvement in the accuracy and completeness of clinical data that result in proper payments. With decades of experience helping leaders advance their risk adjustment strategies, solutions and analytics, we serve accountable care organizations (ACO), commercial, Medicare and Medicaid populations to improve their processes and health care outcomes. Optum risk adjustment experts help leaders to: Benchmark RAF data and apply advanced analytics to identify the prevalence of health conditions Target and customize strategic pathways based on gaps in care and possible improvements Recommend programs and organizational changes to address gaps Apply best practices to develop programs to drive patient and provider clinical engagements and results Understand opportunities to utilize existing electronic medical record systems to capture accurate and complete diagnosis data Help to address compliance requirements through focused solutions centered around improving clinical outcomes Prepare for audits Optum focuses on nine key areas when working with organizations to help create a comprehensive risk adjustment strategy and tactical plans for execution: Submit data for risk adjustments and HEDIS Report results and project financial impact Capture data after intervention Provide data at point of care Perform analytics to identify gaps Engage, inform and educate providers Set program strategy Inform and assist members The Government Accountability Office (GAO) is making five recommendations to CMS to improve its processes for selecting contracts to include in the RADV audits, enhance the timeliness of the audits, and incorporate RACs into the RADV audits. HHS concurred with the recommendations. The second of the five is that the Administrator should modify CMS s selection of contracts for contract-level RADV audits to focus on those contracts most likely to have high rates of improper payments by taking actions such as the following: Selecting more contracts with the highest coding intensity scores; Excluding contracts with low coding intensity scores; Selecting contracts with high rates of unsupported diagnoses in prior contract-level RADV audits; If a contract with a high rate of unsupported diagnoses is no longer in operation, selecting a contract under the same MA organization that includes the service area of the prior contract; and Selecting some contracts with high enrollment that also have either high rates of unsupported diagnoses in prior contract-level RADV audits or high coding intensity scores. gao.gov Segment members and providers Page 3

4 Payer case study: Correcting diagnosis code leakage The challenge: Payer expressed concern about potential leakage of diagnosis codes required for risk adjustment submissions. Leakage is defined as diagnosis data inappropriately dropped between the point of care and receipt by the paying entity. The payer, with more than 4,000 members, had a RAF Score < 0.9 for the last two years. Our solution: The Optum team analyzed data from risk-bearing provider organizations (clinical data from point-of-care systems) and compared it with payer and CMS response files to identify magnitude of leakage. The team then performed root-cause analysis with the provider organizations to identify systems and/or processes causing the diagnosis data to be inappropriately dropped. Optum identified which diagnosis codes captured by providers at the point of care were missing from payer s CMS Risk Adjustment Processing System (RAPS)/Encounter Data System (EDS) submissions. Results: Optum recommended provider and payer system and process changes to eliminate future leakage and assisted the provider and payer in appropriately collecting and submitting the dropped diagnosis data for the current payment period. Examples of the findings include: One capitated provider entity had $250,000 in claims that matched with the plan, but diagnosis data was not submitted for risk adjustment. An additional $1 million in unsubstantiated codes existed for one provider entity (data in electronic medical records (EMR), but no claim or encounter had been sent) for one payment year. We did not have line of sight into the number of dropped member claims. Optum completed a review and put an actionable program in place to address the data leakage in our submission methods and processes. CFO Page 4

5 Optum works with organizations across programs and lines of business to help develop risk adjustment strategies based on your unique organization and marketplace needs. We can assist you in evaluating your current capabilities, creating or improving a risk adjustment strategy or executing risk adjustment tactical plans by identifying suspects, segmenting into appropriate programs and tracking outcomes of interventions. You can choose from our end-to-end services or focus on one area for improvement. Discovery Perform analytics to identify potential coding accuracy improvements and gaps Provide guidance on how upcoming regulations may impact your business Set program strategy and governance Identify immediate and long-term risk areas and improvement opportunities Data leakage evaluation Integration of risk adjustment Identify priority areas of opportunity to close gaps in care across conditions, clinics, physicians and patients Provide risk adjustment education Evaluate financial impact Contract evaluation (current or potential future) Financial opportunity analysis for current population Execution support Execute member and provider engagement programs Inform and assist members Engage, inform and educate providers Prepare for audits Provide data at point of care embedded within existing EMRs Optimize clinical workflow Perform chart review Reconcile and report results Report results and project financial impact Prepare financial valuations and forecasting Review and complete vendor/initiative evaluations Create suspecting reports and identification Create HCC prevalence benchmarking Review documentation and submissions Create programs for retrospective review Recommend actions to improve documentation and education Evaluate submission effectiveness Review submissions for errors and corrections Improve accurate coding and billing compliance Reevaluate and design coding audit and education programs Execute risk adjustment and clinical document improvement (CDI) Programs Improve your competitive advantage Meet with our experts to learn more about how we can help you improve your risk adjustment strategy performance and provider and member experiences. Mary Larson Risk Adjustment Advisory Services Practice Lead mary.j.larson@ Mark Cherry Vice President Health Management Consulting mark.cherry@ Page 5

6 Optum helps leaders make the right changes at the right time Optum Advisory Services specializes in helping health care leaders address their biggest challenges with guidance, insights and precise strategies to help organizations assert control of their future. Guide your organization with precise and strategic insights We ll help you realize your vision by tapping into a team with real-world experience. We start by assessing your organization s position in the marketplace, using the industry s largest health care data asset. We then chart strategic courses with actuarial precision for your organization s greatest sustainable successes. Hardwire meaningful and sustainable results with proven expertise We are more than consultants. We are also operators with real-world health care expertise who can help you hardwire meaningful and sustainable results. Whether it s growing your organization s top line or defending the bottom line, we work alongside you to implement lasting change by drawing upon a unique breadth of financial, IT, operations, analytics and clinical capabilities. Collaborate and disrupt with unique relationships We are here to help your organization thrive. We can help you to create new relationships across the health care spectrum to create new opportunities for value in the financing and delivery of health care. Developing new relationships and cutting-edge business and clinical models can help you to deliver cutting-edge results. What others say about Optum Advisory Services Everest Group Healthcare Consulting Service PEAK Matrix Assessment 2017 Everest Group ranks Optum Advisory Services as a leader among 20 competitors for its diverse capabilities, spanning the entire consulting value chain that caters to payers, care providers and PBMs across the globe. High Market impact Market adoption, portfolio mix and value delivered Everest Group Healthcare Consulting Service PEAK Matrix Assessment 2017 FTI Consulting Navigant Oliver Wyman Aspirants Optum Circle, Eden Prairie, MN Major contenders Cognizant Ernst & Young North Highland Huron Consulting Group Perficient Alvarex and Marsal Chartis Group Impact Advisors Low Low Leaders Deloitte Consulting McKinsey & Company Accenture Optum Optum is a registered trademark of Optum, Inc. in the U.S. and other jurisdictions. All other brand or product names are the property of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. PwC The Boston Consulting Group KPMG Bain & Company NTT Data Health care consulting vision and capability (Vision and strategy, scope of services offered, enabling innovation and domain investments, and delivery footprint) High Unrivaled breadth and granularity of clinical and claims data, including 98 million lives of clinical data and 188 million lives of claims data A team of more than 1,400 experts in health care Serves more than 300 health plans TOP RATED for expertise among Focused Healthcare-Specific consulting firms, based on client feedback and results Optum *Source: 2018 KLAS Healthcare Management Report Work with a trusted partner Clients rated Optum Advisory Services the highest for expertise among Focused Healthcare-Specific consulting firms in the 2018 KLAS Healthcare Management Report. KLAS reported that clients often view Optum Advisory Services experts as trusted partners who help to guide organizational vision and strategy, and solve problems. Optum, with its deep domain strengths, strong data assets, and differentiated consulting pedigree, is positioned well to help health care organizations navigate these winds of change and embrace the digital-first normal. Jimit Arora, partner, Everest Group 2018 Optum, Inc. All rights reserved. WF /18