Risk Adjustment User Group

1. Risk Adjustment User Group September 2009

2. Welcome to the AugustUser 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. www.csscoperations.com/new/usergroup/usergroupinfo.html

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: • Analyst@askriskadjustment.com for Payment Operations • ann.marshall@cms.hhs.gov 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 (2006-2008).

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 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

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) 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