The Financial Impact of ICD-10: Don t Let Risk Adjustment Be an Afterthought
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1 The Financial Impact of ICD-10: Don t Let Risk Adjustment Be an Afterthought Re-Presented October 8, 2015 Presented by: Kim Browning, CHRS, PMP, CHC Executive Vice President
2 2 About Cognisight: Company Overview Full service risk adjustment vendor in Rochester, New York Wholly-owned subsidiary of o Greater Rochester Independent Practice Association (GRIPA) o Rochester Regional Health $2+ billion health system 3 full service acute hospitals 14,000 physicians 150 locations serving Western New York
3 3 About Cognisight: Markets & Services Analytics Chart Reviews o o Retrospective Concurrent Health Assessments o o Prospective Member-Completed Audit Support o o RADV IVA Risk Verification Provider & Coder Training
4 Today s Agenda 4 Why This Matters ICD Heat Map Analysis Top 20 HCCs Provider Engagement Lessons Learned Getting Your Analysis Started Q&A HIX Supplement
5 Why This Matters For plan or organization o Many items relate directly to quality and corresponding risk adjustment dollars o If you re not proactive, by the time you realize there s a problem, it ll be too late 5
6 ICD-10 Heat Map Analysis 6 ICD-9 to ICD-10 ICD-10 Based on ICD-9 History ICD-9 Mapping to ICD-10 ICD-10 Count Based on ICD-9 History 20% 8% 73% ICD9 codes that map directly to one ICD10 ICD9 codes that map to multiple ICD10 ICD9 codes that map to no ICD10 74% 26% ICD10 codes that may map to HCC ICD10 codes that may not map to current HCC model
7 Top 20 HCCs 3 data cuts o Highest volume of members o Highest RAF factor value o Highest total RAF value Need to react to all 3 to maximize results 7
8 Top 20 HCCs: Highest Volume of Members HCC HCC Description Members 8 HCC Factor Value 64% Total RAF Weight % of total Top Diabetes without Complication % Chronic Obstructive Pulmonary Disease % 2 96 Specified Heart Arrhythmias % 3 85 Congestive Heart Failure % Vascular Disease % 5 18 Diabetes with Chronic Complications % 6 58 Major Depressive, Bipolar, and Paranoid Disorders % 7 22 Morbid Obesity % 8 40 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease % 9 12 Breast, Prostate, and Other Cancers and Tumors % Acute Renal Failure % Coagulation Defects and Other Specified Hematological Disorders % Cardio-Respiratory Failure and Shock % Seizure Disorders and Convulsions % Ischemic or Unspecified Stroke % Other Significant Endocrine and Metabolic Disorders % Angina Pectoris % 17 2 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock % Schizophrenia % Protein-Calorie Malnutrition % 20
9 Top 20 HCCs: Highest RAF Factor Value HCC HCC Description Members 9 HCC Factor Value 21% Total RAF Weight % of total Top Pressure Ulcer of Skin with Necrosis Through to Muscle, Tendon, or Bone % 1 8 Metastatic Cancer and Acute Leukemia % 2 82 Respirator Dependence/Tracheostomy Status % Atherosclerosis of the Extremities with Ulceration or Gangrene % Pressure Ulcer of Skin with Full Thickness Skin Loss % 5 70 Quadriplegia % 6 46 Severe Hematological Disorders % 7 71 Paraplegia % 8 9 Lung and Other Severe Cancers % 9 73 Amyotrophic Lateral Sclerosis and Other Motor Neuron Disease % End-Stage Liver Disease % Major Organ Transplant or Replacement Status % Respiratory Arrest % Amputation Status, Lower Limb/Amputation Complications % Protein-Calorie Malnutrition % Parkinson's and Huntington's Diseases % Aspiration and Specified Bacterial Pneumonias % Lymphoma and Other Cancers % Artificial Openings for Feeding or Elimination % Hemiplegia/Hemiparesis % 20
10 10 Top 20 HCCs: Highest Total RAF Value (Volume x Factor Value) HCC HCC Description Members HCC Factor Value 69% Total RAF Weight % of total Top Chronic Obstructive Pulmonary Disease % 1 85 Congestive Heart Failure % 2 18 Diabetes with Chronic Complications % 3 96 Specified Heart Arrhythmias % Vascular Disease % 5 8 Metastatic Cancer and Acute Leukemia % 6 58 Major Depressive, Bipolar, and Paranoid Disorders % 7 22 Morbid Obesity % 8 40 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease % Acute Renal Failure % Diabetes without Complication % Protein-Calorie Malnutrition % 12 2 Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock % Cardio-Respiratory Failure and Shock % Chronic Ulcer of Skin, Except Pressure % Schizophrenia % Ischemic or Unspecified Stroke % 17 9 Lung and Other Severe Cancers % Coagulation Defects and Other Specified Hematological Disorders % Parkinson's and Huntington's Diseases % 20
11 11 Top 20 HCCs: All 3 Categories HCC HCC Description Members Weight Total RAF Highest Vol. of Members RAF Weight 111 Chronic Obstructive Pulmonary Disease Congestive Heart Failure Diabetes with Chronic Complications Specified Heart Arrhythmias Vascular Disease Metastatic Cancer and Acute Leukemia Major Depressive, Bipolar, and Paranoid Disorders Morbid Obesity Rheumatoid Arthritis and Inflammatory Connective Tissue Disease Acute Renal Failure Diabetes without Complication Protein-Calorie Malnutrition Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock Cardio-Respiratory Failure and Shock Schizophrenia Ischemic or Unspecified Stroke Lung and Other Severe Cancers Coagulation Defects and Other Specified Hematological Disorders Parkinson's and Huntington's Diseases Total RAF Value
12 12 Top 20 HCCs: Now What? We have identified the Top 20 HCCs in all three categories o Highest volume 32% 64% o Highest RAF factor value 21% o Highest total RAF value (volume x factor value) 69% Now what?
13 To be successful, provider engagement is mission critical 13 o If providers aren t documenting properly, you ll lose traction with clinical profiling and corresponding reimbursement o Our spreadsheet identifies Top 20 provider groups for each of your data cut categories and drills down to actual provider, when available o Encourage plan outreach to impacted providers Provider Engagement o Identify impacted providers and then discuss next steps
14 Group Name Total HCC Value Total HCC Value Rank Top 20 Highest RAF Values: Groups Top 20 HCC Value 14 Top 20 HCC Value Rank Total Distinct RAF Weight Total Distinct RAF Weight Rank Patients with HCCs University Professional Services OS Hospitals and Clinics Preferred Medical Group St X s Medical Center SR Regional Medical Center Loc. A X Oncology St Y s Medical Center Memorial Clinic Preferred X Medical Center X Medical Group SH Physicians Park Hospital South Hospital South Health Services The Orange Clinic Valley Medical Center The Comet Clinic S Hospital Radiology Associates X s Medical Center Patients with HCCs Rank
15 Provider ID xx43563 xx43435 Physician Group Name Total HCC Value 15 Total HCC Value Rank Top 20 HCC Value Top 20 HCC Value Rank Total Distinct RAF Total Distinct RAF Rank Patients w/ HCCs Smith, OH Hospitals and Clinics William George, Jean- St X s Medical Center Paul xx43428 Preferred Medical Center xx43475 South Hospital xx43485 St Y s Medical Center xx43441 xx45719 Hughes, Jeanette Williams, Peter SR Regional Medical Center Loc. A South Medical Center xx43419 S Hospital xx43191 Connor, Timothy X Health xx43487 Meridian Hospital xx36804 X Laboratory Services xx3414 Valley Medical Center xx51721 X Medical Center xx43273 SR Medical Center xx37468 Clark, Charlene Top 20 Highest RAF Values: Providers X Regional Medical Center Loc. C xx43469 Lake Medical Center xx43504 X Services xx43461 X Community Hospital xx43412 XYZ General Hospital xx43468 Grande Hospital Patients w/ HCCs Rank
16 Develop a spreadsheet that o Ties HCCs to diagnoses o Ties to provider o Maps from ICD-9 to ICD-10 1 to 1 1 to many Naked 9s 16 o Cannot code from mapping tools Provider Engagement: Tying to Provider & 9-10 Mapping
17 Conduct webinars for providers with an emphasis on o PCPs o Cardiologists o Neurologists o Nephrologists Provider Engagement: Next Steps 17
18 Lessons Learned Start now better late than never Keep HCC information for providers brief just what they need to know to improve Data is in many places; be familiar with all your databases data can be anywhere! 18
19 Lessons Learned, cont. 19 Success with queries
20 Getting Your Analysis Started: Medicare Advantage Determining Top 20 HCCs based on prevalence and weight 20 o Current weights for Model 22 can be found in 2014 Announcement Plans/MedicareAdvtgSpecRateStats/Announceme nts-and-documents- Items/2014Announcement.html?DLPage=1&DLSo rt=2&dlsortdir=descending
21 Find number of members with each HCC from Part C Risk Adjustment Model Output Data (MODD) or Part C Risk Adjustment Model Output Report (MODR) 21 o Model Output Data file layout is contained in Plan Communication User Guide (PCUG) Appendices Screenshots on next 2 pages Getting Your Analysis Started: Medicare Advantage, cont. and-systems/cms-information- Technology/mapdhelpdesk/Plan_Communication s_user_guide.html
22 You need your Model Output Data (MODD) Screenshot Getting Your Analysis Started: Medicare Advantage, cont. 22 Recommendation o Convert to Excel and label columns Fastest way to get to prevalence
23 You also need your Part C Risk Adjustment Model Output Report (MODR) Screenshot Getting Your Analysis Started: Medicare Advantage, cont. 23 Member 1 Member 2
24 Find number of members with each ICD-9 (HCC) from EDGE server response files For ease, default to silver metal level and adult HCC model (unless in pediatric medicine) Pull RAF weights from Getting Your Analysis Started: Health Insurance Exchange 24 Plans/MedicareAdvtgSpecRateStats/Downloa ds/announcement2014.pdf Plans/MedicareAdvtgSpecRateStats/Risk- Adjustors- Items/IDC10Mappings.html?DLPage=1&DLEnt ries=10&dlsort=0&dlsortdir=descending
25 Multiple ways to tie claims to providers o Pages Getting Your Analysis Started: Health Insurance Exchange, cont. 25
26 Q&A For more information, please contact: Kim Browning To request a copy of today s presentation, please tvolkmuth@cognisight.com
27 The Financial Impact of ICD-10: Don t Let Risk Adjustment Be an Afterthought Supplement: Early Indications of HIX
28 28 Supplement: Early Indications of HIX
29 29 Supplement: Early Indications of HIX, cont.
30 30 Supplement: Early Indications of HIX, cont.
31 31 Supplement: Early Indications of HIX, cont.
32 32 Supplement: Early Indications of HIX, cont. ns-and-guidance/downloads/ra-instructions pdf
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