Medicare Advantage
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This document provides an overview of Medicare Advantage, including: - Medicare Advantage originated with the 1997 Balanced Budget Act and allows beneficiaries to receive Medicare benefits through private health plans rather than traditional Medicare. - Plans bid annually for reimbursement amounts and are paid a blended rate based on their bid and a county benchmark. Higher rated plans receive quality bonuses. - Risk adjustment factors account for patient health risks and impact reimbursement. Proper coding of conditions is important. - Star ratings, HEDIS, CAHPS, and HOS are used to measure plan quality and influence enrollment and marketing privileges. - EHRs can help capture necessary data and support protocols to improve quality and star ratings.
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Medicare Advantage
- 1. Medicare Advantage Wednesday, March 26, 2014 Disclaimer: Nothing that we are sharing is intended as legally binding or prescrip7ve advice. This presenta7on is a synthesis of publically available informa7on and best prac7ces.
- 2. • Originated with the Balance Budget of 1997 – Addi7on to Part A & B • Part A – Hospitals • Part B – Professional • Part C – Medicare Advantage (MA) – Certain age – Disabled – Sign over benefits to a private HMO – Special Needs Plan for pa7ents with terminal illness (e.g. End-‐ stage renal disease) – Eligibility • Part D – Medica7ons Medicare
- 3. Reimbursement Model • Provided by an index per county • Plan bids to CMS every June – Proposed capita7on per member – Plan benefits – Confiden7al • New packages announced in October • Plan effec7ve January 1 • 5-‐Star Plans get beSer enrollment benefits
- 4. Reimbursement Example • Bid for $500 • Miami-‐Dade County index ra7ng $900 • Balance split between plan and Medicare – Add $200 • Bonus based on star ra7ng – Add $100 • Factor in Risk score – Mul7ply by risk factor, e.g. 2 • Reimbursement calcula7on: 500 + 200 +100 = 800 * 2 = $1600 is reimbursed
- 5. Hierarchy Condi7on Categories (HCC) • Risk Adjustment Factor. • Risk Adjust Process System file (RAPS). • HCC must be assessed once during a calendar year – Assessment must have a corresponding plan of care within the physician note • HCC codes must be capture in the pa7ent chart – Clinical Document Improvement Specialist – Coders • 8 diagnosis codes allowed under 4010 and 12 diagnosis under 5010 • NextGen 8.3 templates have unlimited Diagnosis codes capability with ICD-‐10 • Ability to have claim-‐splidng to submit more diagnosis codes if needed
- 6. HCC Code Management and Recer7fica7on • Integrated IMO search – HCC codes – RxHCC code – Corresponding Risk Adjustment Factor and prompt for a second code if needed to submit diagnosis • Flag for codes not recer7fied in preceding year
- 7. ★★★★★ Ra7ng • Plans rated on 1 to 5 • Five star ra7ng system created by CMS • Ra7ng system components announced in June • Tangible benefits to increasing star ra7ngs: – Bonus for plans who achieve a 4 or 5 stars – Only 5 star plans can market and accept new members year around • Plans with historical low star ra7ng may be removed
- 8. Monitoring Systems -‐ HEDIS • Healthcare Effec7veness Data and Informa7on Set (HEDIS) – Used by more than 90 percent of health plans – Measures performance on important dimensions of care and service • HEDIS Requirements – Required protocols built directly into the Disease Management tab – Alerts when pa7ents are overdue for required tests
- 9. Monitoring Systems -‐ CAHPS • Consumer Assessment of Healthcare Provider and Systems (CAHPS) – Survey to determine which services were offered to members by their plan • Health Outcome Survey (HOS) – Survey to measure pa7ent percep7on of plan effec7veness • CAHPS and HOS Flags – Cannot be influenced directly though the EHR – Flags can be placed in the EHR for CAHPS or HOS survey • Alert shown each 7me the pa7ent is seen or to help ensure that the survey is returned. Reports can be run against these alerts
- 10. Monitoring Systems -‐ Medica7ons • Medica7ons – Compliance required to ensure pa7ent health is monitored – High Risk Medica7ons that a pa7ent is taking • Complica7ons – Controlling medica7ons dispensing impera7ve to 5 star ra7ng, • Leveraging EHR – Clinical Guidelines por7on of Disease Management suggest medica7on based on disease protocols – Formulary checking func7onality
- 11. Meaningful Use (MU) • Eligible Professionals – 80% of services to members of a single plan – MU requirements for MA same as Part B providers. • Do not need to submit on Clinical Quality Measure (CQM) • Reimbursements paid directly to the plan • Specific requirements and dates for registra7on and aSesta7on
- 12. Provider Models • Contract with provider networks for delivery of care • Provider model can either be: – Staff – IPA
- 13. Case Study on Medicare Advantage
- 14. The Partnership • Leon Medical Center in Florida – Faced with ul7matum • Bring organiza7on live on NextGen in 6 months for $1 million or lose MA contract • Team approach to op7mizing Medicare Advantage system and procedures
- 15. The Turnaround • Reshaped organiza7on by focusing on 3 priori7es: – Maintain accurate Risk Score for each pa7ent – Improve the quality ra7ng • Health Screening • Chronic Condi7ons • Consumer sa7sfac7on – Control Costs through u7liza7on management • Implementa7on strategy: – Build a strong team – Ensure providers comply with coding guidelines – Establish workflows that support quality improvements – Implement technology that supports established standards and procedures
- 16. The Accomplishment • Leon Medical Center upgraded the system in 2 months to create a live produc7on environment • Brought live 100 physicians in 7 loca7on in 4 months • Tracked progression via go-‐live scorecard aligned with goals
- 17. The Results • With the $1 million investment: – Qualifica7ons of all primary care physicians for Meaningful Use program • $2 million in reimbursements from CMS – A .2% increase in the organiza7ons CMS Risk Adjustment Factor – Awarded 5-‐Star ra7ng by CMS • Per-‐capita bonus that is rolled back into the clinical service for members • Year-‐round member enrollment
- 18. Medicare Advantage and NextGen
- 19. Medicare Advantage in NextGen • HCC Code check • Applica7on Configura7on – Enable HCC in Prac7ce Preferences. – EHR Master Files – • System Prac7ce Prac7ce Preferences Charge Entry Differen7ate Risk Adjust Diagnosis • “Enable HCC for this pa7ent” checkbox on *Intake – Makes HCC buSon visible
- 20. Medicare Advantage in NextGen
- 21. Medicare Advantage in NextGen • Medicare Advantage one of the most lucra7ve business lines • Quirk Healthcare Solu7ons has teamed with NextGen to develop a Medicare Advantage suite of templates – Ensure capture of HCC scores and assist in maximizing 5-‐star scores • Medicare Advantage plans include addi7onal incen7ves to supplement provider income
- 22. Future State of HCC Template • Panels for managing HCC Codes: – Suspec7ng Condi7ons – Condi7ons reported by Medicare – Outside Condi7ons – Along with Adding to Today’s Assessment • Op7ons to Accept, Deny or Work-‐up • The Medica7on Module alert for High Risk Medica7on with op7on for prescribing non-‐High Rick Medica7on • “Case Management” template to manage pa7ent with a par7cular Diagnosis/HCC code