1. Risk Adjustment User Group
September 2009

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

3. INTRODUCTION

4. 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

5. 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.

6. 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:
for Payment Operations
for Data Validation

7. PAYMENT PROCESS

8. 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%

9. 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 ( ).

10. 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.

11. DATA VALIDATION

12. 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

13. 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 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

14. DATA VALIDATION
CY 2007
Random Sample
To be implemented

15. OPERATIONS UPDATES

16. 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.

17. 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.

18. 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.

19. TECHNICAL ASSISTANCE
UPDATES

20. TECHNICAL ASSISTANCE UPDATES
Next User Group Meeting
October 21, 2009

21. QUESTIONS & ANSWERS

22. CLOSING

23. RESOURCES
Sean Creighton - (Director, Division Risk Adjustment Operations)
Henry Thomas – (Training, Project Officer)
Louis Johnson – (FERAS,GTL)
Chanda.McNeal – (RAS Payment)
Payment Research
Jennifer Harlow
Lateefah Hughes
Ann Marshall (RADV)
LTC
CSSC