Encounter Data Work Group Summary Notes for PACE Organizations: Key Findings and Recommendations

Transcription

1 Encunter Data Wrk Grup Summary Ntes fr : Key Findings and Recmmendatins Wrk Grup 1 f 2 This reprt summarizes the findings f the PACE Encunter Data Wrk Grup cnducted n January 26, Sixty rganizatins participated in this Wrk Grup and included: Alexian Brthers Cmmunity Services LIFE Beaver Cunty Amarill Multiservice Center fr the Life Path PACE Aging LIFE Pittsburgh ArchCare LIFE St. Francis ARDX LIFE UPenn Bienvivir Senir Health Services Lutheran Senir LIFE at Jersey City Brand New Day Mercy LIFE Care Resurces Muntain Empire PACE Cathlic Health LIFE Natinal PACE Assciatin Center Fr Elders Independence Neighbrly Care Netwrk Center fr Senir Independence NewCurtland LIFE CentraCare Nrthland PACE Cherkee Elder Care On Lk Senir Health Services CMS Orange Cunty Health Authrity Cmprehensive Senir PACE CNY CSSC Operatins PACE Greater New Orleans Elder Service Plan f Cambridge Pace Organizatin f Rhde Island Health Alliance PACE ORGANIZATION OF RHODE Elder Service Plan f Harbr Health ISLAND Services PACE Organizatin f Rhde Island Elder Service Plan f the Nrth Shre Palmett Senir Care Flrida PACE Centers Peak PACE Slutins Franciscan PACE, Batn Ruge Pennsylvania PACE, Inc. Henry Frd Health System, Center fr Pittsburgh Care Partners Senir Independence Prvidence ElderPlace Hpkins ElderPlus Riverside Retirement Services IMPAQ Internatinal Senir Care Cnnectin Independent Living fr Senirs Senir LIFE LIFE at Lurdes Senir Link 2/24/2011 Page 1

2 Summit ElderCare Ttal Cmmunity Care Ttal Lngterm Care Ttal Senir Care, Inc. TriHealth SenirLink Upham's Elder Service Plan The primary purpse f the Encunter Data Wrk Grups is t prvide a frum fr cmmunicatin between the Centers fr Medicare & Medicaid Services (CMS), Medicare Advantage Organizatins (MAOs), and Third Party Submitters t determine and discuss issues while creating pssible slutins fr final implementatin f Encunter Data. The gals fr this series f sessins included: Identificatin f PACE specific rules, guidelines, and capabilities in the cllectin f encunter data, Transitin slutins fr PACE plans using the 5010 frmat and diagnsis and CPT cding, and PACE abilities t cllect, submit, and stre encunter data. The expected discussin tpics fr this sessin were: PACE rganizatins brader range f services prvided t beneficiaries than typical Medicare Advantage plans. PACE rganizatins experience with fee-fr-service data. PACE rganizatins capacity t supprt encunter data cllectin and reprting, and the impact t PACE IT infrastructures. The first sessin f the Wrk Grup fcused n addressing challenges and cncerns regarding implementatin f encunter data cllectin in and identificatin f pssible slutins fr these challenges. Intrductin and Review f the Encunter Data Cllectin Prcess Befre pening the frum fr discussin a review f the encunter data prcess, lcated in the fact sheet sent t participants prir t the wrk grup, was described. The fllwing were the primary fcus pints during the review: The primary purpse f the cllectin f encunter data is t recalibrate the Risk Adjustment (RA) mdels based n Medicare Advantage (MA) beneficiary health care utilizatin data. Medicare FFS pricing f the encunters will be used because MA payments t prviders will nt be available. The utilizatin patterns f MA enrllees will be captured in a mdel calibrated n encunter data. By January 2012, encunter data cllectin will be fully implemented. Encunter Data System (EDS) will run in parallel with the RAPS system fr a perid f time until the quality f data in EDS is validated and pricing methds can be analyzed. The flw f the encunter data fllws this prcess: Plans will submit encunter data using the Washingtn Publishing Cmpany (WPC) cmpliant 5010 X12 frmat (837-I, 837-P, and pssibly the 837-D). 2/24/2011 Page 2

3 A TA1 reprt will be returned t the plan if a fatal errr ccurs during frnt-end prcessing. If a submitted claim is rejected and cannt cntinue prcessing, the plan will receive a 999-R reprt. If the claim submitted is accepted and cntinues thrugh the prcessing system, the plan will receive a 999-E reprt. The claim will prcess thrugh the CEM/CEDI mdule edits in the Encunter Data Frnt- End System. The plan will receive a 277CA reprt displaying the status f claims submitted (accepted r rejected). Fllwing EDFES prcessing, 837-I, 837-P, and pssibly 837-D will prcess thrugh the PRICERs in which cntent validatin edits will be applied. Range f Services fr PACE rganizatins are based primarily n staff mdel plans. Services ffered thrugh PACE plans are significantly different frm services cmmnly ffered thrugh standard Medicare Advantage (MA) plans. The fllwing are issues/cncerns discussed by wrk grup participants regarding the PACE plan services, as well as, recmmendatins made during the wrk grup that will assist PACE rganizatins in the transitin t cllectin f encunter data. PACE Plan Services The fcus f PACE is preventative, high quality, hlistic care as ppsed t episdic care which addresses health issues as they arise. PACE plans ffer a brad range f services inclusive f all Medicaid and Medicare services nt prvided by traditinal Medicare r Medicaid plans (cmmunity and institutinal services, cunseling, nutritin services, hme health care, transprtatin, etc.). An example f services prvided n a typical day fr a PACE plan beneficiary is displayed in Figure 1 belw. Administrative crdinatin (such as scial wrk services) is cnducted daily t maintain individual care plans. Many services are prvided thrugh salaried staff and are nt cded r accunted fr thrugh nrmal claims submissin prcesses (i.e., use f HCPCS/CPT r diagnsis cdes). Pricing methds currently in use in FFS d nt describe the services prvided by PACE and are nt cvered thrugh traditinal MA plans. Hme health care, persnal care, and skilled nursing care services, which are prvided at a PACE center, d nt qualify as apprved data surces r types f service fr MA plans. Prviders d nt utilize the current CPT cding system. Many services prvided thrugh PACE plans d nt fit under the rules fr the current CPT cding system. CPT cdes are episdic prblem-fcused and many PACE services are bundled int verall practice expenses. PACE prvides crdinated and integrated care acrss Medicare and Medicaid. There is nt a defined bundary between which gvernment prgram is prviding financial reimbursement. A single encunter may encmpass several different kinds f services, sme f which may be cvered by traditinal Medicare and sme are nt. 2/24/2011 Page 3

4 Fr encunter data cllectin, staff f PACE plans will need t stp the care they prvide in rder t distinguish if each service prvided falls int Medicare, Medicaid, r anther categry, and then cde these services apprpriately. Figure 1: Example f a typical day fr a beneficiary enrlled in a PACE prgram. Hme Care Aide PACE Center External Care Hme Care Aide Hme care aide ges t the hme f the beneficiary and helps with daily needs (dressing, feeding, medicatins, etc). Beneficiary is transprted t the PACE center where a variety f services may be prvided (meals, activities, therapies, medicatin, educatin, etc). Beneficiaries may see an utside physician r specialist during the day, in which case they wuld be transprted t and frm the PACE center by PACE staff. The beneficiary is transprted hme and a hme care aide again helps with daily living needs (meals, laundry, shpping, cleaning, etc). Current Billing and Tracking Prcesses Many services, such as hme care aide services (including meal servings, laundry, and ther daily living services), are billed under a capitated rate and are nt billed separately. Prviders and hspitals bill PACE plans fr services prvided by using invices. Manual billing is cnducted fr external prviders whereby infrmatin is extracted frm claims received using a spreadsheet r DDE, which is then used t transmit data. Encunters with PACE staff are recrded in medical recrds but are nt cded using CPT. PACE services are interdisciplinary and include cnsultatin between prviders, cmmunity rganizatins, and cntractrs t create full time individualized plans f care fr beneficiaries. Sme PACE rganizatins use Electrnic Health Recrd (EHR) systems t cllect/submit service data, hwever EHRs d nt allw cding f PACE services. Encunters are currently dcumented by the number f encunters each discipline has with participants each mnth. Capability f PACE Plans t Supprt Encunter Data Cllectin and Reprting The fllwing are issues and cncerns identified by participants regarding the capability f PACE rganizatins t successfully implement the cllectin f encunter data including infrastructure challenges, adherence t the riginal encunter data implementatin timeline, CPT/HCPCS cding issues, and the significance f data cllected and submitted. 2/24/2011 Page 4

5 Current PACE Infrastructures Issues Identified: Many PACE rganizatins d nt have the prducts and system capabilities t submit and receive encunter data frmats. Financially, many f the prducts and system mdificatins necessary fr implementatin f encunter data cllectin are ut f reach fr PACE rganizatins. Obtaining these prducts and mdifying current system prcesses wuld cst significant sums f mney and wuld be an ecnmic burden t price services prvided. The size and capability f PACE rganizatins is diverse and many wuld nt be able t btain the resurces r prducts needed fr implementatin. Sme PACE rganizatins receive bills in a paper frm and manually write checks fr payment f services and sme rganizatins have established IT systems. Many prviders d nt pt fr electrnic systems and submit mstly paper claims. Participants expressed significant manpwer needed t implement encunter data cllectin and cde PACE services. Participant stated using an EMR t cllect encunters and a team f 10 members was needed slely fr system implementatin f encunter data cllectin. Few PACE rganizatins have hired third party submitters t assist in submitting/receiving 5010 data fr encunter data cllectin encunters received wuld prcess thrugh a third party submitter. The third party submitter wuld extract the data and send back t the PACE rganizatin fr submissin t CMS. Participants Recmmendatins: CMS t assist PACE rganizatins in btaining prducts/sftware r data cllectin tls necessary fr encunter data submissin and prcessing. In the past, CMS prvided sftware/prduct supprt fr Lng Term Institutinal (LTI) hmes when intrducing the cllectin f data fr the Minimum Dataset (MDS). Cntinue the RAPS system fr PACE rganizatin use nly. Adherence t the Encunter Data Timeline Issues Identified: Encunter data cllectin and submissin may be pssible fr sme services prvided by PACE plans (like diagnstic services). Hwever, it may be impssible fr sme services t ever be cllected, cded, and submitted thrugh the Encunter Data System (EDS) due t CPT cding issues and inability t price. It will be hard fr many PACE rganizatins t meet the scheduled deadlines fr encunter data cllectin (EDFES testing, etc.) due t the significant differences in systems prcessing and financial burden. Participants Recmmendatins: Use the 837-I, 837-P, and 837-D t submit diagnstic data nly. 2/24/2011 Page 5

6 CMS wuld include a field t flag PACE specific claims n the 837 frmats and turn ff specific edits unnecessary fr submissin f diagnstic services. RAPS diagnstic data culd be mapped t apprpriate 5010 fields mre readily. Cding and the submissin f internal services in the PACE center wuld still be an issue as these services are received n paper claims. Delay the encunter data timeline fr PACE rganizatins. Participants suggested specific training mdules fr PACE, similar t training methds used in the submissin f the RAPS frmat t the RAPS system. Training will be cnducted starting in June Training mdules specific t PACE will mre than likely be presented. Cnduct a lng-term study f the PACE mdel t identify needed cmpnents fr encunter data pricing. CPT/HCPCS Cding Issues Identified: PACE rganizatins d nt have expertise in CPT r HCPCs cding. One technlgically develped PACE rganizatin reprted hiring cnsultants t assign cdes t PACE services. Hwever, an issue remains f hw t dente services that d nt map t certain cdes. Participants Recmmendatins: Create a custmized cding system fr PACE specific services. An issue wuld remain fr pricing f these services as sme are paid by capitated rate. This wuld cause an enhanced administrative burden fr staff. Significance f PACE Service Data n Encunter Data Cllectin Gals Issues Identified: Due t the small percentage f PACE prgrams and the limited number f beneficiaries per prgram, data cllected frm PACE rganizatins may have n affect n the gals fr cllecting encunter data. Cllecting encunter data n sme PACE services and nt thers may affect the accuracy f recalibrating the mdel. Utilizatin f the standard Medicare cvered services may be lwer fr beneficiaries enrlled in MA plans as ppsed t beneficiaries in a PACE prgram since PACE fcuses n preventative care. Due t this, the true cst f care may nt be captured. The encunter data cllectin prcesses d nt seem t supprt the lgic f PACE which is prviding integrated health care services. Participants Recmmendatins: Evaluate the percentage f beneficiaries enrlled in PACE plans t determine if cllectin f encunter data (data ther than what is required by RAPS) is necessary fr PACE rganizatins. RAPS will n lnger be functinal fllwing cmpletin f EDS testing and parallel prcessing; and PACE plans will have t submit infrmatin thrugh EDS nce RAPS is n lnger functinal. 2/24/2011 Page 6

7 Additinal Questins Addressed Thrughut the Wrk Grup The fllwing are additinal questins addressed by participants during the Wrk Grup. Questins asked by Participants Q1: If edits are relaxed n the 837 fr PACE plans, des this mean that services wuld nt have t be CPT cded? A1: CMS is evaluating the data necessary fr a PACE encunter. Shuld CMS determine a data element is nt necessary, then thse edits wuld be relaxed. Q2: Is it pssible fr CMS t leave the RAPS system in place fr PACE rganizatins t use since it s a smaller ppulatin? A2: There are agency csts t running dual systems lng term. The frecast right nw is fr the Encunter Data System (EDS) t replace the RAPS system nce testing has been validated and cmpleted. Q3: When will CMS decide what the expectatins are fr PACE rganizatins regarding the frnt-end testing scheduled t start March 30, 2011? A3: This tpic will be discussed during the next encunter data prcessing meeting n February 3, CMS will infrm PACE rganizatins f the decisin made by February 10, Q4: If the 837 is used, will the number f diagnsis cdes be limited after RAPS system is n lnger in place? A4: The ttal number f diagnsis cdes submitted will nt be limited. The 5010 will allw 12 diagnsis cdes fr prfessinal encunters and 25 diagnsis cdes fr institutinal encunters t be dcumented, hwever, if mre cdes need t be added plans may just submit the additinal cdes n a separate claim. Q5: Encunter data requires face-t-face interactins fr cding. Will that requirement be relaxed fr PACE rganizatins? A5: CMS is currently evaluating PACE plicies. Q6: If the pricing methdlgy is being created, has CMS cnsidered utilizing wrk grups t identify the varius elements that wuld g int pricing methdlgy (Basing recalibratin f the RA mdel n CPT cdes fr an industry that is paid based n diagnsis cdes may lead t an under reprting f csts)? A6: CMS will explre this ptin. Q7: Is it pssible t build the pricing methdlgy based n diagnsis cdes (If nt, the MA industry will need time t adapt t cllecting and reprting CPT cdes)? A7: As f right nw, CMS des nt plan t change the risk scre calculatin methdlgy. Q8: What data elements des CMS need frm PACE rganizatins ther than ICD-9 cdes? A8: As f right nw, all data elements will be required. 2/24/2011 Page 7

8 Q9: PACE rganizatins fcus n preventing re-hspitalizatins with an average f 20 inpatient claims per mnth in a ppulatin f 400. Is prcessing ging t be based n quality f care and preventin f re-hspitalizatins r will rganizatins be penalized fr having fewer inpatient claims? A9: Pricing will be based n Fee-Fr-Service pricing methdlgy. Q10: Where can the Encunter Data Reprt layut be lcated? A10: The Encunter Data reprt layuts can be lcated n the Washingtn Publishing Cmpany (WPC) website at Q11: Where shuld future PACE/Encunter Data questins be directed? A11: Please submit any future questins t eds@ardx.net. Key Cnclusins and Recmmendatins fr Encunter Data PACE Organizatins Wrk Grup Based n the infrmatin discussed in the Wrk Grup held n, the fllwing recmmendatins are prvided t CMS t ensure successful implementatin f the cllectin f encunter data. Recmmendatins As a first step, it was recmmended that a lng-term study f the services ffered by PACE rganizatins be cnducted t identify the cmpnents necessary fr encunter data pricing. Participants recmmended that CMS extend the initial encunter data deadlines fr PACE rganizatins based n prgress and significant impact n IT infrastructures. Participants expressed the need fr assistance in btaining necessary sftware/prducts fr submissin f encunter data. Participants recmmended the submissin f nly diagnstic infrmatin thrugh the 837-I and 837-P and relaxing edits related t additinal health care services prvided. Participants expressed the need fr extensive training n the Encunter Data System (EDS) and cding system requirements. Actin Items and infrmatin needed frm Participants The next Encunter Data Wrk Grup fr PACE rganizatins will be held n April 27, Wrk grup participants shuld send any additinal cmments r slutin pssibilities regarding encunter data cllectin in PACE rganizatins t eds@ardx.net. CMS will update wrk grup participants regarding the decisin t exclude PACE rganizatins frm the initial Encunter Data Frnt-End System (EDFES) testing phase scheduled frm March 30, 2011 thrugh June 30, 2011 by February 10, /24/2011 Page 8