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
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
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