Medical Appropriateness and Risk Adjustment

Medical Appropriateness and Risk Adjustment

Medical Appropriateness David Rzeszutko, MD Medical Director November 10, 2017

Objectives Medical necessity Value equation Medical appropriateness

Why? To improve the health and lives of our members Change the way care is delivered Engage members in their health Innovate to cover more members

Chronic disease management Working with providers to change care delivery

There is a better way! Health care in U.S. is not performance based and does not correlate with longevity

Quality care -Safe -Timely -Effective -Equitable -Efficient -Patient-centered Institute of Medicine Roundtable 2002 Serious and widespread quality problems exist throughout American Medicine. These problems occur in small and large communities, in all parts of country, and with approximate frequency in managed care and FFS systems. Very large numbers of Americans are harmed as a result Every system is perfectly designed to achieve exactly the results it gets. Dr. Paul Batalden

A general approach Right care Right time Right cost Right place

Value = Quality/Cost Clinical appropriateness Surgical Medical Personal Post-op Fiscal appropriateness Service Site of care Facility or provider Payer Payment

Certificate of coverage Definition of clinically appropriate Medically/clinically necessary Necessary services or supplies

Clinical appropriateness Surgical appropriateness Ensures the right procedure is advised at correct time in disease process Medical appropriateness Optimizes the member for treatment to minimize risk of peri-operative and post-operative complications Personal appropriateness Places emphasis on the member being in charge of their care decisions Post-operative appropriateness of care Proper follow-up care

Prospective surgery patient #1 54 year old machine operator presenting to orthopedist with right knee pain affecting his golf game. Symptoms started two years ago and now he is unable to work his eight hour shift. Past medical history: unremarkable Medications: Naprosyn Exam: 5 7 133 pounds BMI 20 Knee exam: reveals boggy joint with decreased flexion and effusion Imaging: severe medial joint space loss with periarticular cysts

Prospective surgery patient #2 Similar historical accounts and physical exam of the knee with imaging suggestive of severe osteoarthritis. Past medical history: insulin requiring diabetes, coronary artery disease, depression Medications: Naprosyn, insulin, aspirin, Lisinopril, met Forman, atorvastatin, citalopram, OTC fish oil, calcium, vitamin D Exam: 5 7 190 pounds BMI 31.5

Prospective surgery patient #3 80 year old retired machine operator presents with right knee pain affecting his senior golf game with imaging suggestive of severe osteoarthritis. Past medical history: essentially unremarkable Medications: Naprosyn occasionally Exam: 5 7 160 pounds BMI 25.1

One size does not fit all For successful outcome: Providers: Individualize care Appropriateness Priority Health: Coordination of care Medication therapy management Remote monitoring Transportation

Questions?

Risk Adjustment David DeHommel Director, Senior Markets Risk Adjustment November 10, 2017

Objectives By the end of this presentation, you will know: What risk adjustment is How risk adjustment impacts you Your role in the risk adjustment process

What is risk adjustment?

Leveling the playing field Risk adjustment is an actuarial tool used to predict health care costs based on the relative actuarial risk of enrollees and to level set comparisons of wellness among members. (CMS)

What is risk adjustment? Risk adjustment predicts or explains the future healthcare expenditures of individuals based on diagnoses and demographics. Diagnoses Demographics Adjust Future Payment

Information drives reimbursement Reimbursement is impacted by: Diagnoses associated with Hierarchical Condition Categories (HCC) Member demographics 5-star quality rating Other factors Centers for Medicare and Medicaid Services (CMS) uses yearly diagnoses to calculate members risk score Accurate information is essential for accurate payment

General methodology Diagnosis codes submitted by providers Determine beneficiary risk scores Determine riskadjusted reimbursement

Business mandate CMS expects Medicare Advantage health plans to: Improve patient care through the identification of certain risk factors, personalized health advice, and referral to additional preventative services and life style interventions. The single most critical factor for meeting CMS expectations is to have a complete and accurate annual assessment of each member s health status as the basis for driving optimal care and treatment.

Segments Medicare Advantage Marketplace Medicaid

Medicare Advantage The main determinants of risk scores are demographics and diagnoses. Prospective and retrospective review of health status - Chart review - In-home / In-office assessments Part C, Part D and ESRD Model Assigns risk scores to individual members 65+ or disabled

Marketplace The main determinants of risk scores are the same as Medicare Advantage, which are demographics and diagnoses. Affordable Care Act (Individual/Small Group) Concurrent review of health status - Chart review - In-home / In-Office Assessments Budget neutrality, zero sum game 3 models (Infant, Child, Adult) 0-64+ patient age

Medicaid The main determinants of risk scores are diagnoses and State programs. Multi-year lag State sets plan premiums, influenced by budget constraints Aged, blind and disabled (ABAD) Children s Special Healthcare Services (CSHCS)

Assessments In-home or in-office

In-home health assessments Alternative to have a health assessment from the comfort of home to capture full burden of illness, optimize care plan and close 5 star quality gaps. Member/Patient benefits include: Collect and validate demographic information Assess the home environment Share comprehensive results with primary care physician High member satisfaction Continuity of care

In-office health assessments Patient engagement via collaboration with network providers and improve clinical documentation to support coding to the highest level of specificity. Member/Patient benefits include: Comprehensive review of chronic conditions with consideration for new ailments Optimizing relationship with primary care provider Expansion of knowledge in Priority Health member benefits such as free gym memberships and preventive health screenings Coordination of health care appointments with specialty providers

Documentation is key How to get it right the first time

Accuracy matters Coding and medical record requirements All conditions must be documented using the M.E.A.T. concept (Monitored, Evaluated, Assessed or Treated). All chronic conditions must be documented annually in a face-to-face encounter. Diagnosis should be captured to the highest specificity. Medical record must support codes reported on the claim.

Documentation guidelines Remember, if it is not documented it didn t happen! Every diagnosis reported as an active, chronic condition must be documented with an assessment and plan of care, reflecting the M.E.A.T. concept. M.E.A.T. is an acronym used to describe four factors that help providers establish the presence of a diagnosis during an encounter in proper documentation.

Reporting diagnosis codes

ICD-10-CM Coding Guidelines The official ICD-10-CM Coding Guidelines state that a condition must exist at the time of the encounter, affect patient care or management and be documented in order to be coded as a diagnosis. Best practice is to use the ICD code that describes the patient s diagnosis, symptom, complaint, condition or problem. Do not code suspected diagnosis when coding outpatient or in office claims.

Coding best practices Use the ICD code that is chiefly responsible for the item or service provided. Code a chronic condition as often as applicable to the patient s treatment. Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Always code to the highest level of specificity.

Specificity matters Some diagnosis codes risk adjust; others do not. Diagnosis code Diagnosis description HCC number F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate HCC name 58 Major depressive, bipolar and paranoid disorders 58 Major depressive, bipolar and paranoid disorders F32.2 Major depressive disorder, single episode, severe 58 Major depressive, bipolar and paranoid disorders F32.9 Major depressive disorder, unspecified N/A N/A

Your role in risk adjustment It s a team effort: Proactively see patients Bill all assessed conditions on claim Assess all relevant conditions Document in the patient encounter

Questions?