Transcript April 2010 - Palmetto GBA

2009/ 2010 Monthly
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Risk Adjustment
User Group
April 2010
Welcome to the April
User Group
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2010
Introduction
Payment Process
Data Validation
Operations Update
Questions and Answers
Closing
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INTRODUCTION
2010
User Group Process
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All attendees must pre-register
It is only necessary to register once
Retain unique PIN for all sessions
Session will last for one hour
Session slides will be available by
the Tuesday before the session
• Panel will answer questions during
the Q&A portion of the session
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INTRODUCTION
2010
• The 2010 monthly Risk Adjustment
User Group dates are posted on the
CSSC Operations website.
www.csscoperations.com/new/usergroup/usergroupinfo.html
• Please continue to review the
website for updates to this
information.
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INTRODUCTION
2010
Q&A Resources
• User Group Calls cover 2 risk adjustment
areas: Payment Operations and Data
Validation.
• On the calls, subject matter experts are
available from each area to answer
questions.
• To submit questions outside of User Group:
– [email protected] for Payment
Operations
– [email protected] for Data Validation
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PAYMENT PROCESS
2010
• Post transition
• 81% resolved in January 2010
• 91% resolved in February 2010
• 60% resolved in March 2010
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PAYMENT PROCESS
2010
• For 2011, CMS will not implement new risk
adjustment models for:
– CMS-HCC
– CMS-HCC ESRD
• For 2011, risk adjustment factors
– CMS-HCC Model refer to the 2009 Rate
Announcement (published in April 2008)
– CMS-HCC ESRD Model refer to the 2008 Rate
Announcement (published in April 2007).
For more information view the 2011 Announcement at
http://www.cms.gov/MedicareAdvtgSpecRateStats/Downloads/Ann
ouncement2011.pdf
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PAYMENT PROCESS
FAQ
2010
Question –
Why would a beneficiary enrolled
in a plan for more than 12 months
have an RA Factor Type Code of
“E”?
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DATA VALIDATION
2010
• Status Update
CY 2007 Targeted Sample
Medical records submitted
Medical record review next step
CY 2008 National Sample
Medical records submitted
Medical record review next step
CY 2008 Contract-Level Sample
Expect request to go out this
summer
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DATA VALIDATION
2010
• CY 2007 Targeted and CY 2008 National
Sample-specific reports
– Two types of reports
• Technical Assistance Report
• Medical Record Receipt Report
– Expect to receive reports shortly
– It is very important that MA organizations
review and report any issues to the Intake
Medical Record Review Contractor
(IMRRC) as directed
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DATA VALIDATION
2010
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Technical Assistance Report
– Provided to help with addressing potential submission issues
which may impact medical record review findings for your
contract
– Distributed via email to confirmed contacts for a contract:
Medicare Compliance Officer, primary and secondary
contacts
– Examples of some potential issues
• Coversheet does not correspond with documents
submitted
• Pages or margins of medical record are cut off
• Portions of text are obliterated
– To respond to Technical Assistance Report, refer to
instructions that appear on the report and accompanying email
message.
– Do not send any medical record documentation directly to
CMS. Send only to the IMRRC according to instructions for
your audit
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DATA VALIDATION
2010
Medical Record Receipt Report
Identifies documentation received by category
by the IMRRC; categories are:
• Medical Record Only - We received the
coversheet with an attached medical record.
• Coversheet Not Received - We did not
receive the coversheet.
• No Medical Record or CMS-Generated
Attestation - We received the coversheet with
no attached medical record or CMS-generated
attestation.
• Medical Record and CMS-Generated
Attestation - We received the coversheet with
an attached CMS-generated attestation and
medical record.
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DATA VALIDATION
2010
RADV Appeals
• RADV Appeals Regulation
– Medicare Advantage and Prescription Drug
Plans Part C & D Policy & Technical Rule
(CMS-4085-F)
– http://www.federalregister.gov/inspection.asp
x#special
– Final Regulation on display: April 6, 2010
– Expected publication date: April 15, 2010
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DATA VALIDATION
2010
RADV Appeals
• Two Pronged Process for RADV Appeals
– Appeal medical record review determinations
– Appeal payment error calculation
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DATA VALIDATION
2010
Medical Record Review Appeals
• MA organizations may appeal medical record review
determinations from IVC/audit report of findings
– CMS will specify which HCCs are eligible for
appeal
• MA organization appeal to CMS designated hearing
officer
– Appeal-level medical record review conducted
– Decision made by hearing officer
– 2nd audit report of findings issued
• Discretionary CMS Administrator Review
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DATA VALIDATION
2010
Payment Error Calculation Appeal
• Payment Error Calculation Appeals Eligibility Criteria
– MA organizations may choose to appeal CMS’
calculation of RADV, contract-level error-estimate
– MA organizations must adhere to established
RADV audit requirements
– CMS’ payment error calculation methodology is
not eligible for appeal
• Three stage process:
– Reconsideration
– Hearing
– Discretionary Administrator Review
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DATA VALIDATION
2010
• RADV Targeted 2007 Contract-Level
Sample
– CMS will be providing appeals information
• RADV CY 2008 Contract-Level Sample
– Training will be held for selected MAOs
• In-person at CMS, and
• Via Webinar
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OPERATIONS
2010
• Submission Information:
– Same submitter may transmit for several
MA organizations.
– Multiple batches are allowed per Hxxxx
number.
– More than one detail record (CCC) is
allowed per HIC number.
– NPI (National Provider Identifier) is not
required for risk adjustment.
– Once a cluster is submitted and stored, it is
not necessary/required to resubmit.
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CSSC FAQ’s
2010
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Q. Can I delete all the errors I received in my file, to lower
my error percentage rate?
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A. No - claims that receive an error are not stored. In order
for an error to be deleted it must be stored in the system.
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Q. Why is risk adjustment important to physicians and
providers?
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A. The risk adjustment model relies on the ICD-9-CM
diagnosis codes to prospectively reimburse MA
organizations based on the health status of their enrolled
beneficiaries. Physicians and providers must focus
attention on complete and accurate diagnosis reporting
according to the official ICD-9-CM coding guidelines.
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TECHNICAL ASSISTANCE
UPDATES
2010
Next User Group Meeting
May 19, 2010
New participants can register
to attend the UG session
from the www.TARSC.info
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RESOURCES
2010
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Sean Creighton (Director, Division of Risk Adjustment & Payment
Policy)
[email protected]
Henry Thomas (Training, Project Officer)
[email protected]
Louis Johnson (FERAS,GTL)
[email protected]
Chanda.McNeal (RAS Payment)
[email protected]
Payment Research
[email protected]
Jennifer Harlow (RADV)
[email protected]
Lateefah Hughes (RADV)
[email protected]
Mary Guy (RADV)
[email protected]
LTC - www.tarsc.info
CSSC - www.csscoperations.com
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