The Risky Business of Claims-Only Risk Adjustments

Transcription

1 The Risky Business of Claims-Only Risk Adjustments August 3 rd & 4 th, 2016 Presented by: Kim Browning Executive Vice President Vince Bryant Vice President of Business Development

2 Agenda 2 Plan Selection Insights HCC Selection Insights Internal Controls Future of RADV Q&A

3 Selection Insights 3

4 Higher than average risk scores o Bleeding edge of Prospective Does a lot of Prospective Plan Selection Insights Disproportionate volumes of average HCC Recent merger or acquisition Large membership Issues with timely RAPS and Encounter Data submission Little or no deletes Fast growing 4

5 HCC Selection Insights 5 Health Plan 1 Health Plan 2 Targeted Diagnosis No dx detected HCC for provider s with high RAF scores More claims driven than prospective and supplemental Long inpatient stay Cross year inpatient claims o Admitted in 2014 o Discharged in 2015

6 Common concerns o Single source claims o Problematic HCCs HCCs with < 1% average distribution HCC Selection Insights, cont. 6

7 HCC Selection Insights, cont. 7 HCC HCC 1 HCC 6 HCC 8 HCC 17 HCC 27 HCC 34 HCC 46 HCC 70 HCC 71 HCC 73 HCC 74 HCC 76 HCC 80 HCCs with < 1% Avg Distribution Aids Opportunistic Infections Metastatic Cancer and Acute Leukemia Diabetes with Acute Complications End Stage Liver Chronic Pancreatitis Severe Hematological Disorders Quadriplegia Paraplegia Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease Cerebral Palsy Muscular Dystrophy Coma, Brain Compression/Anoxic Damage HCC HCC 82 HCCs with < 1% Avg Distribution Respirator Dependence/ Tracheostomy Status HCC 104 Monoplegia and Other Paralytic Syndromes HCC 110 Cystic Fibrosis HCC 115 Pneumococcal Pneumonia, Emphysema, Lung Abscess HCC 157 Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon or Bone HCC 162 Severe Skin Burn or Condition HCC 166 Severe Head injury HCC 173 Traumatic Amputations and Complications HCC 186 Major Organ Transplant or Replacement Status

8 8 Internal Controls: Pre-RADV Best defense is strong offense Continue to audit vendors o Still need to audit prospective and supplemental

9 9 Internal Controls: Pre-RADV, cont. Big gap in internal controls Risks lurk in claim-driven risk adjustments o Start/increase auditing effort Collaborate with internal audit Enhance claim filters Look for the infrequent HCCs Single source claims If only one diagnosis submitted in review year YIKES!

10 10 Internal Controls: Pre-RADV, cont. Adopt consistent discipline of self audits o Once and done is not enough Know your outliers o Regionally o Nationally

11 11 Internal Controls: Pre-RADV, cont. Medicare Advantage outliers Risk Score Group Strata RAF Average Percent of Population Low < % Medium > % High < 3% Very High > 3.2 < 3%

12 12 Internal Controls: Pre-RADV, cont. Duals outliers Risk Score Group Strata RAF Average Percent of Population Low < % Medium < 20% High > 20% Very High > 3.2 > 25%

13 13 Internal Controls: Pre-RADV, cont. Analytically derived risk points o Members with seven or more HCCs o Members with + 1 in RAF score from prior year o Top 1/3 paid stratum o High distribution HCCs o Presumed red flags Active versus history of Vascular disease Diabetes with complications Major depression Consider a combination

14 14 Internal Controls: Pre-RADV, cont. Know extrapolation methodology and how it applies to your risk adjustments You got this, right?

15 RADV EXTRAPOLATION EXAMPLE # RISK SCORE STRATA MA PAYMENT Hypothetical MA Pymt. Variance Weighted Payment error Deviation Deviation Squared Variance (div by 67-1) TOP 3RD $ 3, $ 3, $ $ 13, $ $ 675, TOP 3RD 3, , (112.18) 12, TOP 3RD 3, , (28.98) (432.54) (141.16) 19, TOP 3RD 2, , (112.18) 12, TOP 3RD 2, , (112.18) 12, TOP 3RD (112.18) 12, TOP 3RD (112.18) 12, TOP 3RD (112.18) 12, TOP 3RD (112.18) 12, TOP 3RD $ - $ (112.18) $ 12, $ 109, $ 101, $ 7, $ 112, $ 0.00 $ 12,710, , Error % 6.89% Enrollee Weight Weighted Enrollee Payment Error $ 112, MIDDLE 3RD $ $ $ $ $ (21.11) $ MIDDLE 3RD , , MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD (36.11) 1, MIDDLE 3RD $ - $ (36.11) $ 1, $ 48, $ 45, $ 2, $ 36, $ (0.00) $ 2,112, , Error % 5.00% Enrollee Weight Weighted Enrollee Payment Error $ 36, BOTTOM 3RD $ $ $ (5.06) $ (75.52) $ (16.05) $ BOTTOM 3RD (10.99) BOTTOM 3RD (10.99) BOTTOM 3RD (10.99) BOTTOM 3RD (10.99) BOTTOM 3RD (8.08) BOTTOM 3RD (10.99) BOTTOM 3RD (10.99) BOTTOM 3RD (10.99) BOTTOM 3RD $ - $ (10.99) $ $ 20, $ 19, $ $ 10, $ 0.00 $ 264, , Error % 3.62% Enrollee Weight Weighted Enrollee Payment Error $ 10, Strata Total $ 177, $ 167, $ 10, $ 159, Standard Error (SE) (Sq of PE) 58, Total CMS Pymt $ 3,900,000 Sample Population (Extrapolated) Confidence Interval CI (2.575*SE) $ 150, Average Error % 6% 4% 5 POINT ESTIMATE (PE) $ 159, PE + Confidence Interval $ 309, PE - Confidence Interval 8, Nh= Roadmap Summary 1 RADV eligibles 2 Total CMS payment (based on monthly premiums) 3 Divide sample into three stratum 4 Weight the stratum 5 Point estimate 6 Standard Error 7 Confidence Interval 8 Upper and lower bounds 9 Lower + FFS adjuster 6 7

16 Future of RADV 16 RAC

17 Future of RADV, cont. 17 RAC R A D V

18 18 Future of RADV: A Little Bit on RAC Program Recovery Audit Contractor (RAC) Program o Selection based on items with a propensity of error o All provider types o Procedure code vs. diagnoses code o Level of care and medical necessity o Looks at both over and under payments o Ongoing audit not an event And don t forget about

19 19 Future of RADV: GAO Recommendations Improve coding intensity calculation o Only include three most recent years of risk adjustment data o Standardize change in disease risk scores to account for expected increase in all Medicare Advantage contracts o Develop method of accounting to separate provider submissions from supplemental record review o Include beneficiaries renewed from different contracts under same Medicare Advantage organization doing pair-year period

20 20 Modify contract selection for contract-level RADVs to focus on those with high rate of improper payments o Select contracts with Highest coding intensity score High rates of unsupported diagnosis in prior contract level RADV audits For contracts no longer in operation, select contract under same Medicare Advantage organization and service area Combination of above for plans with high enrollment o Exclude contracts with Low coding intensity score Future of RADV: GAO Recommendations, cont.

21 Improve RADV timeliness o Closely align timeframe to national RADV o Reduce timeframe between plan selection and audit sample notifications o Improve record transfer reliability and performance o Require defined number of days for audit Improve timeliness of appeals process Future of RADV: GAO Recommendations, cont. Develop plan and timeline for incorporating RAC into Medicare Advantage 21

22 Q&A 22 For more information, please contact: Kim Browning Vince Bryant