The Power of Over Reporting By Vanessa Beers Tejas HMA

How Plans Get Paid Base Premium Risk Adjustment Quality Score Medicare Advantage: Premiums Risk Transfer Subsidies Commercial: PMPM based on Populations Admin cost Medicaid How Plans Get Paid

Medicare Base Premium A base rate is set by CMS for the Payor Adjustments made based on STAR rating Quality Metrics Patient Satisfaction Provider Satisfaction Timely and accurate claims Bonuses to have a 5 STAR rating include not only the higher base rate the but the ability to sell year round.

Medicare Risk Adjustment Throughout the year CMS measures patient health based on claims and data pulled from Provider records Diagnosis Procedure codes Lab results Medications Risk scores are assigned to members and rates are adjusted to accommodate those with more health issues

Risk Adjustment Transfer Payors may no longer deny coverage based on pre-existing conditions. Nor can Payors charge high premiums to those with pre-existing conditions. Throughout the year patient health is measured based on claims and data pulled from Provider records Diagnosis Procedure codes Lab results Medications Risk scores are assigned to members and plans with higher numbers of membership with high risk scores receive additional funds. Payors with low risk scores are charged and funds placed into a pool to be redistributed to Payors with high risk scores.

Diagnosis - Hierarchical Condition Categories 79 high risk condition categories Each category is given a risk factor value Total relative risk factor value indicates the patients’ overall health status Current 2017 CMS-HCC model Proposed 2019 CMS-HCC model Mental Health HCC 57 Schizophrenia HCC 58 Major Depressive, Bipolar, and Paranoid Disorders New: HCC 59 Reactive and Unspecified Psychosis New: HCC 60 Personality Disorders Substance Use Disorders HCC 54 Drug/Alcohol Psychosis HCC 55 Drug/Alcohol Dependence HCC 55 renamed to Drug/Alcohol Dependence, or Abuse/Use with Complications Added diagnoses Added concepts introduced with ICD-10 around Heroin, Cocaine, Opium, Methadone, and other synthetics; LSD; Psychostimulants; and Alcohol New: HCC 56 Drug Abuse, Uncomplicated, Except Cannabis

Diagnosis - Coding Medicare allows up to 12 diagnosis codes on electronic claims Code acute conditions first Add chronic conditions addressed in the same visit Include conditions affecting the patient management

Diagnosis – Clinical Example 1 S – 76 y/o male with sore on right big toe and calf that won’t go away PE – Alert NAD, (+) ulceration (R) plantar great toe. S/P (L) toe amp* non-healing wound. 2 cm ulceration to (R) calf. A – Chronic DM ulcers RLE, Peripheral neuropathy 2* DM, Diabetic nephropathy

Diagnosis – Clinic Example 1 Cont’ Imcomplete Coding Complete Coding E11.9 Diabetes mellitus Type 2 without complications E11.621 Diabetes mellitus with ulcer foot E11.622 Diabetes mellitus with other ulcer L97.209 Ulcer calf E11.21 Diabetic nephropathy E11.40 Diabetic neuropathy Z89.412 Toe amputation status Z79.40 Controlled with insulin

Diagnosis – Clinical Example 2 26 y/o female routine check up suffers from paranoid schizophrenia and diabetes, doing well on medication, continuing with psychotherapy, has started to gain weight. Labs ordered to check possible side effects of medication, A1C and weight control was discussed.

Diagnosis – Clinic Example 2 Cont’ Imcomplete Coding Complete Coding F20.0 Paranoid schizophrenia F20.0 Paranoid schizophrenia R63.5 Abnormal weight gain E11.9 Diabetes without complications Z79.84 Controlled with oral antidiabetic drugs * could also include lab results if received timely

Procedure Codes / Lab Results / Medications Bill all procedures that are not otherwise captured Report lab results in Dx Medications Payors work with labs to receive zero pay claims on prescriptions that are filled without use of Health Plan Providers can file zero pay claims for samples given regularly

Metrics within normal range A1C checked BMI measured Annual exam More Procedures performed A1C BMI Blood Pressure Metrics within normal range Quality Score

Reporting Automating as much information into the claims process Move as much out of Free Text and into structured fields Establish Data Feeds with your Payors Report / file claims on services you don’t expect to be paid Charge Nordstrom rates not Medicaid

Who Benefits Centers Payors Reduces onsite audits Reduces records requests Improves your bonus Increases Payors ability to add Value Added Services Increases your worth to the Payors Allows for higher levels of billing Increases Payors premiums from CMS Improves Payor STAR rating Increases Payors ability to add Value Added Services Improves Payors ability to avoid RAT charges Increases chances of Bonuses