Premier Health Group RAF & Network Meeting. April 30, 2015

Transcription

1 Premier Health Group RAF & Network Meeting April 30, 2015

2 Risk Adjustment Factor Training

3 Agenda What is RAF? The HCC Model Documentation and Coding for RAF The ICD-10-CM Transition Our Ask 3

4 What is RAF? 4

5 RAF Defined Accurate RAF coding drives 4 key factors of a successful population health program Additional Resources Better Analytics Wholepatient view Encourages regular engagement Provides a payer with additional resources to manage the health of a riskier population More accurate coding leads to improved predictive modeling and stratification of a population Creates individual patient profiles that reflect their overall health instead of episodic issues Encourages regular outreach to patients who aren t visiting the practice but may need follow up Used to assess the clinical complexity of a patient and predict the burden of illness for individuals and populations Acts as a multiplier when calculating CMS payments to a payer Factors into the bidding and payment of MA plans Focuses on identification, management and treatment of chronic conditions. 5

6 Why is RAF Important? Capturing appropriate diagnosis codes through the Enhances physicians understanding of the RAF program drives improved patient care and comparative riskiness of their panel Patients with chronic clinical quality. Allows for an accurate account of the conditions cost more to treat population s clinical profile, including and therefore need to be conditions treated by specialists, complications coded accurately and comorbidities The only way to ensure Helps identify previously undocumented appropriate reimbursement suspect medical conditions through integration from CMS is through accurate of disparate patient data using clinical ICD-9-CM coding and physician algorithms documentation Improves accuracy of patient stratification for Fair payment for accurate clinical programs, referral to care manager and treatment care team Helps providers develop comprehensive and coordinated care plans to manage the whole patient Encourages outreach to patients without regular visits to their primary care physician 6

7 Why Should You Engage? As a physician or care team member, you can Capture the true burden of illness for your patient panel Improve identification for care management programs and quality initiatives Drive high quality care through a comprehensive medical record Build a foundation for the transition from volume to value-based care Ensure integrity and compliance with clinical documentation standards Cultivate a partnership with the health system and plan. 7

8 Physician Led Solutions Traditional RAF approach Health Plan led Physician led Value add of provider-led solutions Advantages of a physician-led solution: Physician ownership and accountability for RAF outcomes: Engaged and incentivized physicians actively building comprehensive patient profiles Fewer diagnostic gaps, reducing the necessity for payer involvement in RAF programs Improved care coordination amongst primary care physicians, their patients, and specialists Engagement of embedded care managers, practice managers, etc.: Ensures that RAF efforts are custom-tailored to the individual practices RAF data output can be modified/structured and fed into down-steam analytics (e.g. risk stratification) 8

9 The HCC Model 9

10 Characteristics of CMS-HCC Model The HCC model contains 79 diagnostic categories, reflective largely of chronic conditions experienced in a Medicare population Risk scores for each diagnosed HCC are added together for each patient, as are additional factors for comorbidities (ex. CHF and COPD) Over 3,000 ICD-9 diagnosis codes are used to compile an accurate risk profile Conditions must be documented and billed at least once per calendar year for inclusion in the risk model The model is also calibrated to account for disease severity, requiring coding specificity (ex. diabetes unspecified vs. diabetes with renal complications) 10

11 Characteristics of the HCC Model It s Additive Document and Code all diagnoses specific to each patient Hierarchies and Disease Interactions Patients diagnosed with multiple HCC s in a single hierarchy will be reimbursed at the highest paying HCC Additional payments are offered when certain diseases coincide When these diseases are present in the same patient, CMS recognizes a higher cost associated with treatment which necessitates an increased payment Examples include: CHF and COPD CHF and Renal Disease 11

12 The HCC Model DM Hierarchy HCC and Risk Score *17 Diabetes with acute complications* Risk score *18 Diabetes with neurological or other specified manifestations Risk score *18 Diabetes with renal or peripheral circulatory manifestations Risk score *18 Diabetes with ophthalmologic manifestations Risk score *19 Diabetes, no complications Risk Score Sample Associated Dx/ICD-9-CM Codes Diabetes with ketoacidosis Code: 250.1x Diabetes with neurological manifestations Code also manifestation, e.g. DM polyneuropathy Codes: 250.6x, (357.2) Diabetes with renal manifestations Code also manifestation, e.g., DM nephropathy Codes: 250.4x, (583.81) Diabetes with ophthalmologic manifestations Code also manifestation, e.g., DM retinopathy Codes: 250.5x, ( ) Diabetes mellitus Code: *Hierarchy 12

13 The HCC Model Neoplasm Hierarchy HCC and Risk Score HCC 8 Metastatic Cancer and Acute Leukemia Risk score HCC 9 Lung and Other Severe Cancers Risk score Sample Associated Diagnoses Secondary malignant neoplasm of bone and bone marrow Acute lymphoid leukemia remission Malignant neoplasm of liver primary Malignant neoplasm of upper lobe of lung HCC 10 Lymphoma and Other Cancers Risk score Malignant neoplasm of adrenal gland Hodgkin s disease HCC 11 Colorectal, Bladder and Other Cancer Risk score Malignant neoplasm of transverse colon Malignant neoplasm of cervix HCC 12 Breast, Prostate and Other Cancers and Tumors Risk Score Malignant melanoma Malignant neoplasm breast 13

14 Characteristics of the HCC Model Sample HCCs HCC 22 Morbid Obesity New HCCs HCC 124 Exudative Macular Degeneration Sample Associated Diagnoses Body Mass Index of 40 or greater, Adult Exudative macular degeneration HCC 135 Acute Renal Failure HCC 136 Chronic Kidney Disease (Stage 4-5 and ESRD) HCC 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon or Bone Acute kidney failure Chronic kidney disease stage V End Stage Renal Disease Pressure ulcer stage IV HCC 158 Pressure Ulcer of Skin with Full Thickness Skin Loss Pressure ulcer stage III HCC 159 Chronic Ulcer of Skin, Except Pressure Ulcer of heel 14

15 Documentation and Coding for RAF 15

16 Important Elements of RAF Coding ICD-9-CM is the official diagnosis code set for risk adjustment payment Role of the provider is to capture and document all conditions that are treated, managed, or affect patient care during a face-to-face visit Coded diagnoses must be supported by medical record documentation including, evaluation, assessment and treatment plan Accurate coding and documentation is crucial for accurate risk profile 16

17 Central Tenets of High Quality Documentation Quality documentation captures all conditions that are assessed, treated, managed, and which affect patient care at each visit, or at least once a year Conditions need to be captured during a face to face visit by a Physician, Nurse practitioner or Physician Assistant in an office visit, hospital, or outpatient setting Assess all conditions that coexist at time of encounter Consider disease specificity and comorbidities Accurately code all diagnoses and submit on a claim 17

18 RAF Coding Process Conduct RAF Assessment during a face-to-face encounter Document appropriate conditions in patient s medical record (Treat, Evaluation, Assessment or Monitor - TEAM) Apply the specific ICD-9-CM code(s) to the claim 18

19 2014 Documentation Quality Results Example #1 Condition comorbidities specified Management plan Conditions treated by specialists included Conditions under management included Status of conditions specified Example #2 The physician used suggested verbiage from the worksheet to detail that the condition was managed by a specialist, with a follow-up visit scheduled Each condition is thoroughly assessed in A&P with discussion of status and future management Medication plan and specifics are provided 19

20 Coding Issues 29% of encounters reviewed had Doc./Coding issues Case study: Physician evaluates conditions on the worksheet but neither bills nor documents conditions A Evaluate conditions on worksheet B Bill conditions Despite evaluating 6 chronic conditions from the assessment worksheet, the physician only billed V70.0 (physical exam). C Document conditions None of the checked conditions were evaluated in the A/P section of the medical record. 20

21 Appropriate RAF Coding - Example The example below showcases appropriate coding/billing and documentation. The assessment and plan section treats, evaluates, assesses and monitors (TEAM) the presented conditions HPI Sally comes into the office today with labored breathing and shortness of breath. Pt. has a history of COPD and Congestive Heart Failure. A/P COPD Exacerbation Patient currently taking Spiriva. Will increase dosage and patient will follow-up with pulmonologist. CHF Currently stable. Patient will continue on Lasix ICD-9-CM Code Description HCC Risk Score Obstructive Chronic Bronchitis with Acute Exacerbation Congestive Heart Failure, NOS Total RAF Score

22 Documentation Tips A code cannot be justified in the record if the diagnosis is only listed on the Problem List Auditors cannot connect diagnosis with medications or treatment plans the physician must do this in the documentation Codes billed on a claim should be assessed/treated by the provider in the Assessment and Plan Appropriate Documentation Language Examples Chronic condition X is stable and will continue current management. Chronic condition Y s management requires the following interventions/ changes Chronic condition Z is currently managed by a specialist with a scheduled follow up visit. 22

23 Patient Centered Primary Care (PCMH) Model and RAF PCMH is a care model that includes a comprehensive, team based, coordinated approach to patient care. The Primary Care Team is wholly accountable for a patient s physical and mental health care needs and coordinates patient care across the broader health care system. The Primary Care Physician evaluates the management of patient chronic conditions and documents the associated treatment plans. In the CMS-HCC model: Can a Primary Care Physician bill a diagnosis code that he is not treating? Yes, it is the responsibility of the Primary Care Physician to capture all conditions and monitor the treatment of those conditions. 23

24 Documentation Tips Linking Conditions Coders can only code what is documented by the provider Diagnoses relationships cannot be assumed or inferred Related conditions must be linked together in the medical record If two or more conditions are related, the provider must use the appropriate verbiage in the MR so that the correct code(s) can be assigned Diabetic Linking Examples Diabetes with Retinopathy Retinopathy due to Diabetes Diabetic Retinopathy 24

25 Appropriate RAF Coding Properly Linking Conditions A/P Patient with chronic kidney disease stage IV due to type 2 DM that has been well-controlled by insulin. The patient also receives dialysis on a regular basis at the outpatient clinic. The dialysis has been currently going well. Patient also had below-knee amputation last year. No noticeable infection present. ICD-9-CM Code Description HCC Risk Score Diabetes with renal manifestations, Type II or unspecified type, not stated as uncontrolled Chronic kidney disease stage IV, requiring chronic dialysis V45.11 Renal dialysis status V49.75 Below Knee Amputation, Status Total RAF Score The Aim: Ensuring a comprehensive patient profile is documented and billed annually 25

26 Non-Specific Language Using symbols such as +,, or will not infer a diagnosis Abnormal lab values do not equate to a diagnosis Provider must use definitive language to bill a condition blood pressure indicates an elevated blood pressure reading, not hypertension GFR < 15 on its own should not be coded as Renal Failure. Renal Failure must be documented in the note in order to code it Probable CKD cannot be billed as CKD. Do not use question of or rule out 26

27 HCC Coding Example A/P Patient is here today for chest congestion. Chest x-ray and cultures reveal Pneumonia. She has sugar and hx of Heart Problems with current edema. Chest is wheezy with rales. Plan to increase fluids, monitor glucose readings, and antibiotics. How can we make this note better? ICD-9-CM Code Description HCC Risk Score 486 Pneumonia, Unspecified Abnormal blood sugar Cardiovascular disease, unspecified 0.0 Total RAF Score 0.0 The documentation above does NOT support submitting these diagnoses. 27

28 HCC Coding Example A/P Patient is here today for chest congestion. Chest x-ray and cultures reveal pneumococcal pneumonia. She has diabetes controlled by diet and Metformin. Chest is wheezy with rales. Plan to increase fluids, monitor glucose readings bid at home, and oral antibiotics. Patient has Chronic Systolic CHF with present edema. Will continue Lasix. Patient is to call for glucose readings over 200 and return for a follow-up appointment in one week. ICD-9-CM Code Description HCC Risk Score 481 Pneumococcal Pneumonia Diabetes mellitus, Type II or unspecified type, not stated as uncontrolled Chronic Systolic Heart Failure Total RAF Score Takeaway Being as specific as possible will boost risk score in some cases. 28

29 Can t Miss Chronic Conditions Morbid Obesity (BMI >= 40) Major Depressive Disorder CHF COPD Diabetes with and without manifestation(s) CKD I - V & ESRD Atrial Fibrillation Malnutrition PVD 29

30 ICD-10-CM Transition 30

31 ICD-10-CM is Coming Finally We Think 4/7/2015 CMS 2016 Announcement CMS cannot accept or process ICD-9 codes for risk adjustment for services with dates of service beginning October 1, Additionally All entities covered by HIPAA must use ICD-10 for dates of service starting October 1, 2015, which includes health care providers and payers who do not deal with Medicare claims but are covered entities under HIPAA Full transition to 2014 HCC Model ICD-10-CM Preliminary list on CMS website 31

32 ICD-10-CM Transition ICD-9-CM vs. ICD-10-CM ICD-10-CM requires greater coding accuracy and specificity ICD-9-CM currently has 13,000 codes, ICD-10-CM has nearly 70,000 ICD-9-CM consists of 3-5 numerical digits, ICD-10-CM is alphanumeric and will consist of 3-7 digits ICD-10-CM allows for condition laterality, which is limited in ICD-9-CM CPT/E&M/HCPCS codes will remain unchanged 32

33 ICD-9 vs. ICD-10 Coding Structure ICD-9 CM Example: ICD-10-CM Example: 33

34 ICD-10 Coding Structure Example Chronic gout due to renal impairment, left shoulder, without tophus (tophi) 34

35 Appropriate RAF Coding ICD-10 HPI Jon comes into the office today for a check-up on his Diabetes. Pt. has a history of CKD and Congestive Heart Failure. A/P Type II DM with Stage IV CKD Patient currently stable and will follow up with nephrologist. Chronic Systolic CHF Currently stable. Patient will continue on Lasix ICD-9-CM Code E11.22 Description Type 2 diabetes mellitus with diabetic chronic kidney disease HCC Risk Score N18.4 Chronic Kidney disease, stage IV I50.22 Chronic systolic (congestive) Heart Failure Total RAF Score

36 ICD-10-CM Transition Bizarre ICD-10-CM codes: R46.1-Bizarre personal appearance Z73.1-Type A behavior pattern Z Sibling Rivalry Z63.1-Problems with the in-laws X52-Prolonged stay in weightless environment W56.22xA-Struck by orca, initial encounter W61.62-Struck by a duck, sequela V95.42xA-Forced landing of spacecraft injuring occupant, initial encounter S308.67A-Insect bite (non-venomous) of anus, initial encounter V97.33xD-Sucked into jet engine 36

37 Brief RAF Quiz 37

38 Question Which of the following conditions could be coded from the example below? Answer: A/P 1)Congestive Heart Failure Stable: Patient will continue on IV Lasix with scheduled Cardiologist follow-up next month 2)Hx of COPD 3)DM II: Currently stable and managed on insulin 4)HTN 5)Probable CKD: Scheduled to see nephrologist next week A. COPD and CHF B. CHF, DM II C. CHF and DM II, Hypertension D. CHF, COPD, DM II, and high blood pressure 38

39 Answer Which of the following conditions could be coded from the example below? Answer: A/P 1)Congestive Heart Failure Stable: Patient will continue on IV Lasix with scheduled Cardiologist follow-up next month 2)Hx of COPD 3)DM II: Currently stable and managed on insulin 4)HTN 5)Probable CKD: Scheduled to see nephrologist next week A. COPD and CHF B. CHF, DM II C. CHF and DM II, Hypertension D. CHF, COPD, DM II, and high blood pressure 39

40 Question What conditions can be captured from the example below? A/P 1)ESRD Stable today. Patient currently receives dialysis MWF. Scheduled to follow up with his nephrologist next week. 2)Type II Diabetes Stable on insulin. Answer: A (Diabetes with renal manifestations), (ESRD) B (Diabetes, type II or unspecified), (ESRD), (V45.11) Dialysis status C (Diabetes with renal manifestations), (Diabetes, type II or unspecified) D (Diabetes with renal manifestations), (ESRD), (V45.11) Dialysis status 40

41 Answer What conditions can be captured from the example below? A/P 1)ESRD Stable today. Patient currently receives dialysis MWF. Scheduled to follow up with his nephrologist next week. 2)Type II Diabetes Stable on insulin. Answer: A (Diabetes with renal manifestations), (ESRD) B (Diabetes, type II or unspecified), (ESRD), (V45.11) Dialysis status C (Diabetes with renal manifestations), (Diabetes, type II or unspecified) D (Diabetes with renal manifestations), (ESRD), (V45.11) Dialysis status 41

42 Our Ask 42

43 Ask of Practices and Physicians A Practices Take ownership of making RAF successful and help to integrate with other quality initiatives Provide feedback on what works and suggest how other aspects could be improved B Physicians C Staff Continue excellent care for Premier MA patients Assist with scheduling and early identification Utilize HCC coding guide : document, and code Premier Medicare patients health conditions each calendar year Incorporate appropriate conditions into patients problem list and validate annually Ensure accountability and facilitate smooth office processes Help prepare worksheets, validate completion of progress note and coding, submit worksheet 43

44 The Bottom Line It s good for the health of your community Max reimbursement means the payer has resources to put toward population health technology, clinical programs like PATH, and people/processes that help us identify, reach, and impact the health of patients with varying degrees of need. It s good for physicians While revenues initially flow to the payer, physicians should share in the benefit and receive up to $100 per completed RAF form per patient. The RAF process should help capture a complete 360 view of the patient to support informed medical decision-making. It s good for our patients Patients should be assessed, treated, and cared for based on their complete health profile, not just relevant conditions of the day. It s good for your practice The RAF program provides education, processes, and tools for capturing the health status of all the health plan patients which will help practices manage the population. It s good for the system, and the plan CMS will pay more to care for patients with significant health conditions. If we accurately score the health profile of our patients, we can earn what s available from CMS for treating these patients. Improved accuracy = max reimbursement. 44

45 Thank you for attending today s session. Questions? Whitney Smith, MBA, RHIA wsmith@evolenthealth.com Phone: (678)

46 Premier Health Group Network Update Network Outcomes and Initiatives

47 Agenda Review 2014 Outcomes and 2016 Offerings Incentive Plan and Structure 2015 Updates 47

48 Agenda Review 2014 Outcomes and 2016 Offerings Incentive Plan and Structure 2015 Updates 48

49 Our Commitment Expand and better support the relationship between care providers and patients by leveraging a connected team. Use technology to transform patient data into actionable information. Make access to care easier for the patient. Create a simplified, better coordinated care experience. Shift incentives to reward better health. Our Mission We will build healthier communities 49

50 2014 Employee Benefit Plan Key Takeaways: Total medical plan paid decreased by 3-4%. Medical admissions were down by 27% due mostly to a 24% reduction in Ambulatory Sensitive Admissions. ED utilization was down 23% due to fewer (likely avoidable) visits. Note: These statistics represent data from January 2014 to September

51 2014 Network In 2014, more than 3,000 physicians, APNs and PAs composed the PHG network. Those physicians offer more than 70 specialties to our community. PHG provided care in nine counties in Southwest Ohio. 51

52 2014 Network Lessons Learned In-network vs. out-of-network provider education Pre-authorization list Provider portal familiarity Preventative Care V and G codes Modifier 25 For provider issues or inquires, please contact Provider Services at (855)

53 Sales Outcomes to Date 7,129 MA members (Premier Health Advantage) 115 D-SNP members (Premier Health Advantage VIP) 2,078 Individual members (Premier HealthOne) 561 Commercial group members 17,223 Premier Health employee members In total, PHG manages 27,106 lives 53

54 2016 Sales Offerings Medicare Advantage Plan Dual Special Needs Plan (D-SNP) Individual Plan (On & Off Exchange) Commercial Large Group Fully-Insured Commercial Group Self-Funded (ASO) For groups with more than 25 employees 54

55 Agenda Review 2014 Outcomes and 2016 Offerings Incentive Plan and Structure 2015 Updates 55

56 Incentive Model Development Premier sought to develop a PCP incentive model that is: Triple Aim Driven Optimizing patient health Offering superior care Delivering highest value care Population-health focused Based on carefully selected metrics that are Better Health Lower Costs Better Care impactful, achievable, and aligned with payer contracts Rewards individual and collective performance And is ultimately a model you can financially optimize with strong performance 56

57 Overview: Incentive Opportunities Line of Business PAF* worksheet completion Complex Care Visit completion Medication adherence Complex Case Rounding Post Discharge Visit RAF HCC Addressed rate Medicare Advantage Stars Generic drug dispensing rate Premier Health Advantage X X X X X X X X Premier Health Business Value X X X Premier Health Employee Plan X X X Aetna Payer Partnership X X X X *Patient Assessment Form 57

58 2015 Premier Health Plan Payment RAF Star Category Pop Health Measure (efficiency) Pharmacy (efficiency) Complex Case Rounding Post Discharge Visit 2015 Quarterly Payments $150 per completed and correctly entered worksheet Up to $1 PMPM for each of three medication adherence measures: 1) Diabetes, 2) Hypertension 3) Cholesterol* Goal: >81% at TIN level for each adherence metric $200/$100/$100 for Complex Care Visit completion $50 per round $40 per visit 2015 End-of-Year Payment (Paid out in 2016) Variable $ PMPM based on TIN performance on RAF HCC Addressed rate. Paid out in Q $5 PMPM for 4 Star performance across all Star measures at the H-level (i.e., whole network) Paid out in Q $0.50 PMPM for each point of Generic Dispensing Rate above 86% at TIN level Paid out in Q *Payout schedule: payout in July for 1/1-6/30 performance at $0.50 PMPM per metric, payout in October for 7/1-9/30 period based on 1/1-9/30 performance at $0.75 PMPM per metric, payout in January for 10/1-12/31 period based on 1/1-12/31 performance at $1.00 PMPM per metric

59 PMPM View of Premier Health Plan MA Opportunity 2015 Activity Payments $10.63 PMPM worksheet payment 2015 EOY Outcomes Payment $2.50 PMPM at 85% addressed rate 2015 EOY TOTAL PAYOUT $13.13 PMPM $0.74 PMPM for Medication RAF Adherence Measures Star $1.00 PMPM for RX GDR (88% rate) Efficiency $1.91 PMPM for Complex Care (including rounding) Total Opportunity $14.28 PMPM $5.00 PMPM for 4 star H Level performance $7.50 PMPM $5.74 PMPM $1.00 PMPM $1.91 PMPM $21.78 PMPM 59

60 Incentive Frequencies Line of Business PAF* worksheet completion Complex Care Visit completion Medication adherence Complex Case Rounding Post Discharge Visit RAF HCC Addressed rate Medicare Advantage Stars Generic drug dispensing rate Premier Health Advantage Paid Quarterly Paid Quarterly Paid Quarterly Paid Quarterly Paid Quarterly Paid Yearly Paid Yearly Paid Yearly Premier Health Business Value Paid Quarterly Paid Quarterly Paid Quarterly Premier Health Employee Plan Paid Quarterly Paid Quarterly Paid Quarterly Aetna Payer Partnership Paid Quarterly Paid Quarterly Paid Quarterly Paid Quarterly *Patient Assessment Form 60

61 Agenda Review 2014 Outcomes and 2016 Offerings Incentive Plan and Structure 2015 Updates 61

62 2015 Goals Closed-loop referrals Identifying best performing physicians to create a preferred provider network within PHG PCP/Specialist availability survey Re-credentialing process to begin 2015 To-Dos (please refer to your folder) Participating Provider Agreement Incentive Amendment signed Payor Partnership Network (PPN) agreement signed Electronic Fund Transfer (EFT) application signed 62

63 EMR Updates EMR benefits Continuity of Care Transparency of information The goal of EMR updates EpicCare Link CareEverywhere 63

64 Appendix

65 What is the RAF HCC Addressed Rate? RAF HCC Addressed Rate= Rate at which patients assigned to providers have all clinical / diagnosis coding opportunities addressed and documented in their record Each provider s addressed rate is calculated based on the following formula: All survey items that are recorded as confirmed, not applicable/condition not present, or other with a written explanation Addressed Rate Sum of all survey items 65

66 RAF HCC Addressed Rate Performance at the TIN (Yearly) Addressed rate is the rate at which patients assigned to providers have all clinical opportunities/needs addressed Activity and Payment Which patients? Example Variable $PMPM based on TIN performance on the HCC addressed rate These incentive dollars are in addition to the PAF worksheet completion incentive if the TIN performs above 84%. Premier Health Advantage 50 patients with 86% of opportunities addressed is: 50 x $2.50 x 12 = $1,500 $2.50 PMPM value Months per year Payment table 66

67