Risk Adjustment User Group September 2009

Welcome to the August User Group Introduction Payment Process Data Validation Operations Update Questions and Answers Closing

INTRODUCTION

INTRODUCTION User Group Process All attendees must pre-register It is only necessary to register once Retain unique PIN for all sessions Session will last for one hour Session slides will be available by the Tuesday before the session Panel will answer questions during the Q&A portion of the session

INTRODUCTION The 2008 monthly Risk Adjustment User Group Q & A, Notes, and Technical Assistance documents are posted at the CSSC Operations website. Please continue to review the website for updates to this information. www.csscoperations.com/new/usergroup/usergroupinfo.html

INTRODUCTION Q&A Resources User Group Calls cover 2 risk adjustment areas: Payment Operations and Data Validation. On the calls, subject matter experts are available from each area to answer questions. To submit questions outside of User Group: Analyst@askriskadjustment.com for Payment Operations ann.marshall@cms.hhs.gov for Data Validation

PAYMENT PROCESS

PAYMENT PROCESS Prior to transition 38% response rate Post transition 89% resolved in June 95% resolved in July 58% resolved in August Overall response rate since February 89%

PAYMENT PROCESS 2009 Payment Impact CMS implemented a system wide fix to correct hospice payments made to MA organizations; Release is scheduled for October payments; 432 Contracts; 1629 PBP's; 18,055 Beneficiaries; Total impact spans across multiple years (2006-2008).

PAYMENT PROCESS Frequently Asked Question (FAQ): Could you show us where we might find CMS guidance for FT G1 and G2 for 2009? More specifically, what are the relative factors? When we analyzed some of our members who had transplants in 2009, their risk factors per the MMR did not match our calculations/outcome.

DATA VALIDATION

DATA VALIDATION CY 2007 Pilot RADV (notified June 20, 2008) CMS is providing MA organizations with the option to submit corrective medical records and attestations Deadline for submission of corrective medical records and attestations is Wednesday, Sept. 16, 2009 CMS will not extend the submission deadline

DATA VALIDATION CY 2007 Targeted Sample (notified Nov. 10, 2008) Reconfirmation of selected MA organizations’ (MAOs’) MCO and primary and secondary contacts CMS’ contractor, Healthcare Management Solutions (HMS), will soon distribute an email request Please respond within 2 business days, as requested Instructions Packet Will provide information on the attestation, documentation dispute and appeals processes CMS will provide training to selected MAOs MA organizations will have 12 weeks to submit medical records & attestations

DATA VALIDATION CY 2007 Random Sample To be implemented

OPERATIONS UPDATES

OPERATIONS Frequently Asked Questions Q:    Is there a rule against plans submitting a hospital inpatient other (02 provider type) diagnosis cluster without an inpatient primary (01 provider type) diagnosis cluster? A: While there are no submission requirements limiting plans to only submitting 02 provider type diagnosis clusters without an 01 diagnosis cluster, there may be implications regarding validation and reporting.

CSSC OPERATIONS Reminder CMS added a new edit to the system for plans submitting large files to the FERAS test environment. The new edit will enforce the limit of 3,000 CCC records in an individual file submitted into the test environment. FERAS will reject files with greater than 3,000 CCC records, and the rejected file will return an edit of 166 (Test file cannot exceed 3,000 records). Organizations with continued non-compliance in submitting individual files exceeding 3,000 records in the test environment, without permission, may face disciplinary actions by CMS, which may include their ability to submit data.

CSSC Operations Reminder Continued: Reasons for permission on TEST files: If you are a new plan If you have a new system or if current system moved to another location If you had system maintenance updates (one time courtesy) If plans implementing new logic to extract duplicates (one time courtesy) You must contact CSSC Operations prior to any test file submissions. NOTE: Organizations include Plans and Third Party Submitters. Since June 18, 2009 (Implementation date) there has been 298 test files submitted with a total of 2,198,567 CCC records.

TECHNICAL ASSISTANCE UPDATES

TECHNICAL ASSISTANCE UPDATES Next User Group Meeting October 21, 2009

QUESTIONS & ANSWERS

CLOSING

RESOURCES Sean Creighton - (Director, Division Risk Adjustment Operations) Sean.Creighton@cms.hhs.gov Henry Thomas – (Training, Project Officer) Henry.Thomas@cms.hhs.gov Louis Johnson – (FERAS,GTL) Louis.Johnson@cms.hhs.gov Chanda.McNeal – (RAS Payment) Chanda.mcneal@cms.hhs.gov Payment Research analyst@askriskadjustment.com Jennifer Harlow Jennifer.Harlow@cms.hhs.gov Lateefah Hughes Lateefah.Hughes@cms.hhs.gov Ann Marshall (RADV) Ann.marshall@cms.hhs.gov LTC www.tarsc.info CSSC www.csscoperations.com