RISK ADJUSTMENT: Plans and Groups Sharing Information.

Next to the roll out of PART D, the implementation of Medicare’s HCC Risk Adjustment reimbursement model for Medicare Advantage plans is one of the most significant changes to the Medicare industry. In 2007 plans will receive 100% of their reimbursement based on the HCC Risk model that pays higher rates for beneficiaries who have chronic conditions and less for healthier beneficiaries. The health of a beneficiary is based on the professional, inpatient and outpatient diagnosis data submitted to CMS by plans.

In order to maximize reimbursement plans, groups and providers need to WORK TOGETHER to code accurately and completely capturing all of the diagnosis’s that pertain to a beneficiary. Any breakdown in the flow of information will result in lower payments. Here are some changes in the relationships between plans, groups and providers.

PLANS NEED TO SHARE INFORMATION DOWNSTREAM – Plans receive MMR and MOR reports from CMS with demographic, eligibility and HHC updates from CMS. In order for groups to also identify gaps in the data that CMS is paying on and the information in medical records, plans must share this information with groups and providers. The Industry Collaboration Effort (ICE) has issued a draft release of a reconciliation report that plans can provide to groups that share all of the key information that CMS is reporting. Groups will use this report to identify what diagnosis codes are in their qualified encounter data and is not showing up in the CMS data reported to plans. The best scenario is where plans and groups both adopt a standard communication format reducing the costs to managed the process.

COLLABORATION AND REVIEWS – We encourage all groups to work closely with each plan they manage beneficiaries for. In these meetings the plan and MSO need to review the impact of the collaborated effort in raising risk scores, identifying gaps in data adopt best practices from other groups and plans.

If you have any questions on how to design or implement a risk adjustment program we at Dynamic Healthcare Systems would be more than happy to meet with you and review your current efforts. You can contact us at info@dynamichealthsys.com.