2014 completed, now is the time to start planning for HEDIS®
2015. While the active medical record collection period is short, HEDIS®
is a year round activity. There are many opportunities that can be acted on now to make next results even better for many it’s a matter of data gaps and identifying where those gaps exist and taking action to close them can drastically improve your HEDIS®
and STARs rates next year.
CLOSING THE GAPS
2014 results with claims data throughout the year can give you an insight into where data gaps with quality of care measures that impact HEDIS®
and STARs results. When analyzing this information, you can identify interventions for your health plans, providers and members. It is important to prioritize interventions by the impact they can yield.
For health plans, consider what is driving your gaps.
- Are gaps resulting from network leakage due to members visiting providers that are not participating with the plan and aren’t obligated to provide medical record information? If so, work with your benefits department to identify ways to message members about in-network benefits.
- Are there large provider groups that are resistant to cooperating?
- Do they have EMR? What incentives can you provide to encourage participation?
Engage provider network management to find ways to work with challenging provider groups now to make HEDIS® 2015 smoother. Are there other supplemental data sources that can help improve rates. For example, investigate state registries for immunizations.
Provider engagement is another key way to improve HEDIS® 2015 and Stars results. Providers are challenged with day-to-day operations of their offices and may not have the resources available to identify members needing preventative screenings or chronic care management. Targeted reports providing them with up-to-date patient information can assist them in their outreach efforts to encourage members to receive timely care. In addition, identify ways to offer providers options for HEDIS® 2015 that can reduce provider intrusion. Do they have EMR that can be accessed remotely? Do they want to schedule early so they can anticipate and schedule your HEDIS requests with other plans? Sometimes it’s the little things that make the provider’s life easier that can help with getting the responsiveness you need for your HEDIS® data collection.
The health care system is challenging to navigate. By making it easier to understand, members can become more engaged in managing their health. Depending on your membership demographics some outreach efforts are more effective than others. Consider a multi-prong approach such as mailings, voicemail and health educator outreach to members based on preventative screenings and chronic care management. Optimize care management programs to remind and follow-up with members needing services. Sometimes members need a call to action and some guidance – it’s a win-win. Members get the care they need and you get the needed information to help them maintain or improve their health.
By focusing now internally and collaborating with providers and members, you can design interventions to impact the data in time for HEDIS® 2015 and close the gaps that exist.
By Elizabeth Micholovich, Senior Project Director, Health Data Vision, Inc.
The new rule published on May 19, 2014, revises the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations to implement statutory requirements, improve program efficiencies, clarify program requirements, and improve payment accuracy for Contract Year (CY) 2015 in general. The provisions in the rule are effective immediately.
The final rule is accessible here.
Health Data Vision has analyzed these new rules and how they affect Risk Adjustment processes for Medicare Advantage plans. This blog summarizes and comments on the most significant points of these rules.
Problem: Tightened timeframes
Improving payment accuracy: The final regulation would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. After the final risk adjustment deadline for a payment year, MA organizations will be allowed to submit data to correct overpayments but cannot submit diagnosis codes for additional payment. The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must report and return overpayments.
This requirement effectively tightens the timeframe in which Plans will be incentivized to verify the diagnosis that have been submitted through claims. Once outside that window, plans will be required to return over-payments without the ability to submit corrected diagnosis codes. Thus leaving only a downside for the health plans. For this reason Verify or Delete will become a much more sought after mechanism during chart reviews, particularly ahead of January sweeps.
HDVI’s addresses these tightened timeframes with the Verify, Delete plus Add functionality in our Workflow Platform.
Problem: More RADV’s More Often
Improved MA risk-adjustment data validation (RADV) audit appeals procedures: The rule strengthens RADV by streamlining the RADV audit appeals process by combining error rate calculation appeals and medical record review-determination appeals into one combined process. The streamlined process will reduce administrative burden on both MA plans and CMS.
CMS is making efforts to streamline the entire RADV process. The working assumption is that it will create a system where more plans can be audited on a regular basis. If this assumption is correct HDVI will see more demand for RADV assistance.
HDVI already has a strong automation service for RADV that reduces the effort and time required for RADV responses, while eliminating the majority of uncertainty and negative financial impact. Learn more about HDVI's Mock RADV.
Problem: Critical Reporting Measures
Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.
CMS has now incorporated the requirement to improve health for Medicare Advantage members. This means that reporting results of chart audits will become critical information to filter back to the plan for improvement initiatives. The reporting results will need to be audit specific, DOS specific and provider specific, which will require much more work than before. Computer assisted coding, error resolution and extremely efficient record retrieval are necessary in order for health plan’s to facilitate the increased volume before the reconciliation deadline.
With HDVI's Real-time Analytics and Secure Virtual Print Technology, increased volumes of health plan reporting are handled with ease, while (SVP) reduces provider abrasion.
Problem: Identifying Revoked Providers
Permit revocation of Medicare enrollment for abusive prescribing practices and patterns: CMS is adding the authority to revoke a physician’s or eligible professional’s Medicare enrollment if:
CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or the pattern or practice of prescribing otherwise fails to meet Medicare requirements; or
His or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked; or
The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs.
Providing CMS the authority to revoke such prescribers’ Medicare enrollment will help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse.
It is not clear how CMS intends to track or communicate these revoked physicians, likely through the NPI/Taxonomy database. NPI is now a required submission element, so it is possible that CMS will simply reject certain NPI’s. This should be monitored closely in order to learn more and how to avoid submitting diagnoses from providers that are no longer permissible to treat Medicare Members.
A National Provider Database is frequently updated and available in HDVI’s Workflow Platform.
By Kristen Joyce, HDVI - Senior Director, Risk Adjustment
Exchange participation is creating new challenges as more health plans enter health insurance exchanges and realize a solid Risk Adjustment model must be planned, built, and set sail before a tidal wave of transfer payments hits their deck. Imminent threat of revenue loss due to poor data collection processes may sink otherwise thriving plans as they watch their money being swept back to sea by the rip current known as ‘reallocation of premium’ or risk adjustment transfers. Further loss of future revenue looms large as plans with poor risk models skip the opportunity to shore things up with quick and proactive provider education. And the oncoming tidal wave of CMS measures are challenging for even the industry experts. To stay afloat, commercial plans must change course from a ‘selecting and protecting’ to an ‘absorbing and distributing’ risk model.
Do Medicare Advantage Risk Models Translate?
Medicare Advantage plans have been navigating these waters for some time now, but experts agree, retrofitting a commercial plan with a MA Risk Adjustment model isn’t smooth sailing. For one thing, data audit timelines are different and tightly compressed for risk adjustment activities and reporting in the exchanges. The timing is much shortened from data-submission to payment adjustments. Another thing exchange plans will have to contend with is a smaller percentage of suspects, which at initial glance seems to lighten the administrative load, but in actuality, can be brutal to the results of even slightly inefficient plans. To provide some insight into the financial impacts of your plan’s risk adjustment activities, the Congressional Budget Office estimated that we could be seeing $10 BILLION PER YEAR in risk adjustment transfers.
Data & Revenue: Choice of Workflow Platform Critical
Health plans will be paid with levels of member health status taken into account, as reported by the health plan through their data collection activities. This plan revenue, as explained in HHS regulations, will take into account member ages, genders, and documented diagnoses. Since this information is privacy protected, the data and plan payment scores will remain housed within each individual health plan’s technology platform. Of course, HHS regulations include auditing of this data, not once but twice by both your health plan auditors, while HHS determines your audit sample, and then again by HHS auditors. Therefore, the workflow platform chosen by the health plan is critical to maximizing the efficiency of data management and revenue optimization.
Since at this point, no one knows exactly what the audit data points will consist of, it makes choosing and building the most transparent and controllable data platform a must for health plans. Transparency of the process, scalability and control will all play into the health plan success or failure to correctly extract quality audit data. Financial and compliance implications, and significant operational workload will certainly beach health plans who drag their heels and are slow to launch. Health plans options to design, test and implement risk models necessary to participate in exchange business include the option to purchase a scalable software platform.
What is the Financial Alignment Initiative?
As a part of the Affordable Care Act, two new offices were created within Centers for Medicare and Medicaid Services (CMS) to test new payment and service delivery models that fully integrate care for dual eligible beneficiaries. Dual eligible beneficiaries receive both Medicare and Medicaid benefits. These beneficiaries typically include low-income seniors and younger people with disabilities and have complex and often costly health care needs.
These newly created offices, the Medicare-Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation Center, partnered to create the Financial Alignment Initiative (otherwise referred to as the “Dual Demonstration”). This an opportunity for states to test models with two possible approaches (Capitated or Managed Fee-for Service) to align financing between Medicare and Medicaid while sustaining or enhancing the quality of care provided to Medicare and Medicaid enrollees. The benefits under both models include primary, acute, pharmacy, behavioral health and long-term services and supports currently covered by Medicare and Medicaid. In addition, plans can offer additional supplemental benefits not covered by Medicare or Medicaid.
Capitated and Managed Fee-for Service (MFFS) Models
The capitated model utilizes a prospective payment methodology where the health plan will receive a blended payment to provide care for the enrollees. A three-way contract between the State, CMS, and the health plan is established. CMS and the State will jointly select and monitor participating health plans. In this model, the anticipated savings are shared between CMS and the state. States approved for the capitated model to date are the following: California, Illinois, Massachusetts, New York, Ohio, South Carolina, Virginia, and Washington.
Under the MFFS model, the state is responsible for the beneficiaries care coordination and the providers will be reimbursed on a fee-for-service basis (by CMS for Medicare services and by the state for Medicaid services). MFFS utilizes a pay for performance methodology where the State benefits from the savings initiatives implemented to improve the quality of care and reduction in costs. The State would receive a retrospective performance payment for meeting specific quality metrics, demonstrating statistically significant savings in Medicare, and an overall reduction in Federal spending on Medicare-Medicaid enrollees. States approved for the MFFS model to date are the following: Colorado and Washington.
Process to become an Medicare-Medicaid Plan (MMP) under the Capitated Model
To participate in the Dual Demonstration, a State submits a letter of intent to CMS. These proposals vary in such categories as eligibility, covered geography, enrollment mechanisms, implementation dates and phase-in plans, benefit packages, beneficiary protections, stakeholder engagement, quality measures and oversight. There is a lot of variation as each state incorporate existing programs and state specific factors into their proposal. CMS will then work to establish guidelines that outline the overall expectations in a Memorandum of Understanding (MOU). A Medicare-Medicaid Plan (MMP) is a health plan that has applied through the State and CMS application process to participate in the Demonstration and has been approved via a joint process. The next step is for the State, CMS and the selected MMPs to enter into a three-way contract which provides guidance to the plans in order to implement the new programs.
By Shana Carrico and Alison Garton of Carrico & Garton Group
CGG provides clients with holistic solutions to operationalize new opportunities and optimize existing ones. CGG works with clients to solve complex operational or systemic challenges to ensure compliance, optimal performance and enhanced revenue.
The delay of ICD-10 is an opportunity for coders to improve their knowledge of ICD-10 as well as share this knowledge and insight with physicians. Health Data Vision encourages health plans, along with their coding/audit managers, to work together to offer ICD-10 training materials to their internal staff. This will keep everyone concerned knowledgeable and ready for the 2015 implementation date.
A considerable amount of time, effort and money has been spent preparing for ICD-10 preparing for the Oct 1, 2014 implementation date, without extensions or exceptions. Now the implementation date has been extended until at least Oct 1, 2015. We believe that just like any other skill, if you don’t use it you lose it. With the delay in the implementation, for at least another year, coder’s should make efforts to remain proficient. In order to do so, coders must practice. We suggest that health plans, physician offices and coders take advantage of all ICD-10 training resources being offered by industry leaders such as AAPC and AHIMA.
This is the perfect time and opportunity to express the importance of detailed and necessary diagnostic documentation with physicians. ICD-10’s specificity of the reporting comes as a significantly expanded code set, 69,000 compared to 14,000 in ICD-9, and a higher responsibility to be clear in documentation. Coding managers and health plans need to take this additional time to provide physician education on proper documentation necessary for ICD-10.
Please keep in mind that this should not only be left up to the health plan, coders should also step forward and help their physicians’ by offering advice on how to better document their patient visits. The choices will be much more specific and require more detail in the medical record when assigning the appropriate code for the patient’s condition. Training physicians to know their choices now will make the ICD-10 transition easier for all parties involved.
As we all know, change is not easy, but how we react to the change determines how successful we are. Regardless of how we feel about the delay of ICD-10, what we must do is embrace the change, keep preparing ourselves as coders and educate our physicians.
At Health Data Vision we realize most Health Plans are at about the halfway point, or hopefully a little beyond, for their 2014 HEDIS data collection projects. This is when it gets fun and it is truly the last time to really be able to address problems before it’s too late. Here are a few things a plan can do to make sure they are on track at the HEDIS season mid-year point and eliminate surprises in May.
Whether you have an experienced review team or long standing relationship with your vendor, it is beneficial to take advantage of the convenience sample. Even if it is just a couple of charts from each of the measure groups, the convenience sample can help you in ways beyond verifying abstractors understanding of the measure. It provides a test run for your chart retrieval processes before the actual MRRV. It also ensures that all necessary chart meta data is pulling over correctly and it allows your auditor to provide some feedback that could in fact make the MRRV process less stress inducing.
Data downloads from your vendor
If you haven’t done so yet, you should be getting at least their first data download. Once a project has been in the field four to six weeks, a sufficient amount of positive hits should be in place for each measure. Then your plan can begin to assess how they are tracking toward goals, and evaluate if they are ahead or behind the pace of prior years. By week eight, weekly to semi-weekly downloads are advisable.
Reset daily throughput targets and assess staffing level
Slow starts or delays in getting projects to the field can still be overcome, but the time to act is now. The most important thing to know is what your daily throughput needs to be for all project steps - from scheduling to chart overread. If you are going to need to add staff to get the work done, don’t hesitate to escalate that request to your senior management. Any grouchiness that you will encounter now, for having to tap resources from other parts of the organization for the next three weeks, will be nothing compared to the outrage that is likely to be vented if your plan falls short of goals for preventable reasons.
HEDIS Best Practices Checklist
On March 9-11 Health Data Vision, Inc. (HDVI) attended and exhibited at the 8th Annual Rise Summit in Nashville, TN. With over 600 in attendance there were many common issues brought up in seminars and in conversations, such as the 2015 CMS regulations, concerns around ICD 10 later this year and the importance of proactively mitigating risk of inaccurate submissions.
The Importance of Verify or Delete plus Add and the 2015 CMS rules
Health plans should make sure they are taking every precaution around avoiding overpayment refund, which would be discovered in a RADV Audit or other imminent audits. A proven method to address this is to review all submitted diagnoses and make sure to delete those that are not truly supported in the chart documentation, instead of only adding. “It may hurt to remove a diagnosis during a Verify or Delete cycle, but it’s nothing compared to what can happen if it gets picked up as an apparent systematic occurrence through RADV,” cites Kristen Joyce, Senior Director of Risk Adjustment at HDVI. If inaccuracies are not identified and removed, then subsequently discovered during a RADV, the cost to the plan in penalties will be much higher than any potential payment the plan may have received for that diagnosis. During his presentation at the conference, Anker J. Goal (a partner at McDermott Will & Emery), identified four methods to affect validation rate, these include:
• Provider education – documentation and coding
• Identify and delete unsupported codes
• Prospective visits
• Audit readiness: record retrieval and review procedures
HDVI’s has developed a set of tools within the MRCS platform designed specifically to help health plans proactively mitigate risk, including our Verify Delete or Add Module and our RADV and Mock RADV Modules, as well and as analytics that will allow for the identification of specific error type trends that can be useful input to provider education efforts and care management efforts.
PROPOSED RULE - Issued January 10, 2014
What is it?
According to CMS the proposed rule would revise the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement statutory requirements; strengthen beneficiary protections; exclude plans that perform poorly; improve program efficiencies and clarify program requirements. The proposed rule also includes several provisions designed to improve payment accuracy.
To achieve all of this, CMS is proposing several changes which necessitate timelier monitoring of beneficiaries chronic conditions. The proposed rule would require health plans to remove erroneous diagnostic data from the Risk Adjustment database, with strong incentives to accomplish this prior to reconciliation (no more “deliberate ignorance”). The proposal also includes requirements for plans to make reportable efforts to improve beneficiary’s health outcomes (no more “reckless disregard”). CMS is further proposing that these new requirements be tied to STARS, thereby rewarding Health Plans that pursue improved health outcomes for Medicare Advantage members.
CMS is also proposing a 6-year look-back window, in conjunction with the new mechanism for over-payment reporting, on any errors found after the reconciliation submission (“constant diligence”). This process (already established) requires a plan to detail the operational flaws that allowed the error to occur, the number of beneficiaries it affects, the estimated total over-payment and what corrective actions the plan will take to prevent it from recurring.
What does it mean for health plans?
It would seem that CMS expects Health Plans to review all Medical Records, identify and remove all errors, and most importantly identify and close all gaps in care prior to reconciliation. If resources and physician tolerances were limitless this would be achievable, but we all know neither is.
So this means that Health Plans will need to revise chart audit targets. Gone are the days of suspecting to capture dropped or missed HCC diagnoses in an effort to maximize revenue. Instead, plans are expected to focus audits on potential errors and potential gaps in care.
However, plans shouldn’t expect that medical record documentation and encounter data will improve simply because CMS has strengthened the program reliance on it. Therefore, there will still be the same need to audit charts to obtain comprehensive diagnostic profiles where encounter data implies a documentation gap. The change here is that when plans identify assessment or documentation deficiencies in this process, CMS is expecting efforts in operational improvements to insure that the member’s care is not deficient and that errors are removed.
The “timely” requirement is the larger challenge. Plans are expected to: analyze lagged encounter data; target errors, deficiencies and gaps; review targeted charts, and react to the results optimally in the same data collection period.
The silver lining here is that identifying gaps in care should inspire follow-up, managed and coordinated care. This effort should not only close any gaps in care, but will also trigger appropriate revenue for any HCC conditions assessed and treated, as well as improve STARS ratings.
What should plans be doing to get ready?
There is no time to be wasted. CMS alerted MAOs this time last year that in 2014 there would be requirements for clinic follow-ups on Home Assessments to insure that all reported HCC conditions were being treated. The message there is that CMS is not paying plans for diagnoses, but rather for managing chronic conditions. This requirement is in place now, and there is no basis to believe that the proposed chart audit requirements will not be in place this time next year.
Health Plans should be making plans now for this expectation. If we assume that CMS will require reporting on health outcomes next year, plans will need to be ready.
Health plans should be making every effort to identify potential encounter data errors for 2011 through 2014 dates of service. Any diagnosis not supported by assessment notes should be deleted. Any gaps in care or documentation deficiencies identified for 2013 or 2014 should be referred for Care Management activities.
Health plans should begin now developing new targeting strategies to maximize health outcome results and documentation. Rather than targeting members, plans should begin targeting clinical areas for enhancements. The average plan will find Diabetes, Heart Conditions and Lung Conditions to be those with the highest drop-off rates. This is largely due to the ability to manage these conditions pharmaceutically. These conditions may appear to be un-treated from reviewing the documentation, when in fact they are not.
Currently at HDVI we are working with our Risk clients to review all reported HCCs and to identify cases where clinical assessments are necessary to manage the care continuum and document chronic conditions appropriately. Additionally, our MRCS Platform has modules specifically designed to improve a health plans ability to assess the quality of documentation supporting a diagnosis and to take decisive action to ensure submissions will pass muster with CMS.
This will help to identify the unique cluster of conditions that each of our clients will need to develop enhanced Care Management activities to insure the care continuum is not broken in the future, as well as highlight documentation deficiencies to support physician education activities.
I recently participated in a panel on this topic at a Medicaid conference and gave it some more thought. This post summarizes what I took away from that discussion.
I am always skeptical of buzzwords and fads. When the hype subsides, we realize that promises were unrealistic and our expectations way too high. However, there is usually a kernel of value that can be extracted. That is true for Big Data, too.
Before we get into Big Data in healthcare, however, let’s define the term: paraphrasing Wikipedia, Big Data is just a whole lot of data. So much, in, fact, that traditional technologies and approaches cannot keep up with processing and analyzing it fast enough. According to studies from McKinsey Gartner, and others, data is being generated at staggering rates each year, with volume reaching Exabytes (a million Terabytes) and even Zettabytes (a billion Terabytes) each year. The Kaiser Family Foundation predicts that the volume of healthcare data accumulated each year will grow 50-fold between 2013 and 2020. So much for that.
To me, a more useful approach to the topic is to look at the technologies and tools that have evolved to manage and analyze these massive amounts of data. That is more of a Silicon valley approach, driven by having hit hard limitations of what off-the-shelf technology could handle. Google, Facebook, LinkedIn and certain research have had the most need for these technologies to date and, in my opinion, do for the most part remain most relevant to these extremely high-volume data operations.
Another way to look at the technology is by categorizing structured and unstructured data and how technology has evolved to specifically handle the latter. Historically IT has been dealing predominantly with structured data, at worst attempting to force unstructured data into a schema one form or another. Today we see a proliferation of unstructured data, a big driver for the need for new technologies and approaches.
So what about healthcare data, then? Well, I would contend that in the realm of healthcare, we are still dealing with predominantly structured data. Even though it is sensible to argue that taking all the data from all of the many flavors of EMR can only be considered as unstructured data, if we take the data of each system individually, we return to a structured world. So it’s just inconsistently structured. Now, that does not make it less painful to deal with, but I’d like to stipulate that anyway.
Meanwhile, the challenges in healthcare remain the old ones: Quality of data, the feeds and the processes around it, defining and maintaining systems of record and reconciling all other versions of the same data around it. Now, the Big Data movement has brought us some technologies that are also very useful with structured data: new analytics tools, statistical evaluation tools and data visualization (we at HDVI are starting to use Tableau 8.1 both internally and as part of our SaaS platform). These tools are very useful, also when used with more traditional technologies. And that should really be the takeaway for us in Healthcare IT. Whether the technology is SQL , SAS or Hadoop (distributed File system) is really secondary to what should always be our primary goal: that the technology addresses a specific need when pragmatically applied to business requirements.
President & CEO
HEALTH DATA VISION, INC.
As we are making our final preparations for the 2014 HEDIS® season, most of us have undoubtedly taken care of the big ticket items related to HEDIS® preparation, such as—vendor selection and performance guarantees, development of measure chase logic, and notifying the network of the upcoming intrusion. There are, however, some less obvious actions that a plan can take in preparation for the upcoming HEDIS® season that can make a big difference in HEDIS® rates.
- Don’t get caught with unusable supplemental data. Rules for using supplemental data have tightened up for 2014. This means everyone needs to take extra care to make sure their supplemental data is auditable, has a documented QA process around it, that it’s collected in a standard way, and is mapped correctly into analysis files.
- Don’t be without network management support from provider relations. Avoid wasting time trying to get into resistant provider offices by articulating a clear strategy for engaging the network team to assist in gaining access.
- Carefully review your provider data when your chase files are generated. Take special care to scrub out specialties or locations that do not make sense for the measure. This will save you time and money, and allow you to focus limited resources on more fruitful activities.
- Inspect your lab data. There are critical flags that can help you quickly identify if you may be missing information. For example: what percentage of tests are for A1c and LDLs, and are they consistent?
- Provide your vendors with as much information as possible regarding your past performance on hybrid measures and what your goals are for 2014. This will help your vendors immediately see the delta between the goal and initial hybrid rates, and allow them to employ appropriate prioritization and retrieval strategies throughout the project.
HEDIS Best Practices Checklist