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Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps

Transforming Risk Adjustment Through Insight, Transparency and Control. Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps. July 30, 2019. Welcome. Lisa Pouncey Senior Director of Product Management 30 Years in Data Management 12 Years HealthCare

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Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps

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  1. Transforming Risk Adjustment Through Insight, Transparency and Control Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps July 30, 2019

  2. Welcome Lisa Pouncey • Senior Director of Product Management • 30 Years in Data Management • 12 Years HealthCare • EMR/Billing Systems/Meaningful Use • Health Plan Claims Processing • 10+ Health Plans — 10 Data Analysts Babel Health • Risk Adjustment Submission Platform • EDPS/RAPS/MMP • Medicaid • APCD • Data Analytics and Management Tool • BPO/Professional Services

  3. Agenda • Introduction • Defining the gap between claims processing and encounter reporting • Where do plans go wrong? • Updating the Endgame • Showstoppers and successes • Top 4 processing mistakes that contribute to lost risk revenue • Incorporating technology and encounter workflow for remediation • Q&A and summary

  4. Defining the Gap

  5. Defining the Gap Claims Processing: Endgame: Heart and soul of the plan Known book of work Established processes Claims system technology supports claims payment Pay right amount Right provider Right services Right members

  6. Defining the Gap Claims Processing: Endgame: New kid on the block Not fully understood Still evolving processes Partial or one way encounter technology Report right data Right format & agency Right health outcomes

  7. Data Errors Claims Payment Report Outcomes Defining the Gap

  8. What’s In It for You? ERROR POOL can correlate to BIG DOLLARS Members: 30,000 Claims: 6% Can’t Send, 4% Rejected 90% Accepted, 66% Risk Eligible -$5,900,000.00

  9. Updating the End Game Show Stopper Successful Response • Establish the Reason to Change • Prepare a business case comparing cost of changing processes or technology to the cost of not changing • Illustrate the cost of repair is greater than the cost of prevention • Same Place Same Thing Syndrome • This is the way we have always done it • Changing processes/technology costs money

  10. Business Case: Internal

  11. Updating the End Game Show Stopper Successful Response • Risk Adverse — Fear of Change • Rejecting dirty claims will result in provider backlash • Manage the Fear — Nothing to Lose but Net Loss • Your plan is not the only plan in need of clean data • 3-month strategy — engage leadership and the provider network to prepare the providers • Offer quality incentives after 6-12 months of clean data

  12. Business Case: Provider

  13. Is it more important to correct a $20,000 claim or $200 claim? IT DEPENDS

  14. Rethink Your Correction Process • Prioritize error correction by risk impact and not by dollars paid • Easily quantify the error pool to target those that are going to have the most financial impact • Need to clean up every episode and not just one (which is the past approach)

  15. How Do You Prioritize Without a Tool • CMS publishes a list of all the procedure codes for risk eligible encounters. Check procedures of the encounters in your error pool against the CMS list. • Available via: Click here for a list of procedure codes

  16. CMS Procedure Codes

  17. How Do You Prioritize Without a Tool If you can’t cross-check the error pool against CMS procedure codes: Prioritize professional and institutional encounters that are not: Home Health: Bill Type 31X Skilled Nursing: Bill Type 21X Inpatient Rehab: Bill Type 72X-76X Hospice: Bill Type 81X or 82X Transportation: POS 40 or 41 Laboratory/Diagnostic Imaging: Bill Type Various 1 2 3 4 5 6

  18. What to Tackle: Big Bucks vs. Little Bucks Error pool can be broken down into categories of some bucks and no bucks Within the some bucks listing, you want to prioritize between: and • Compare against CMS’ HCC (hierarchical condition category list): • Diagnosis codes B20, B97 are related to HIV • Diagnosis codes that start with C are related to cancer • Diagnosis codes that start with D are related to blood and immunity • Diagnosis codes that start with E are related to diabetes, malnutrition and weight • Diagnosis codes that start with F are related to drug dependency and alcohol abuse • Diagnosis codes that start with I are related to heart, kidney and vascular disease • Diagnosis codes that start with J are related to COPD • Diagnosis codes that start with T are related to depressive disorders BIG little

  19. Top 4 Processing Mistakes: Lost Revenue 1 Not maintaining current procedure code/procedure code modifier, and not comparing code effective dates to claims dates of service for proper usage. Ranked #1 and #3 respectively in CEDI’s Top 10 errors of January 2019 2 Not loading the MMR into the claims system to validate MBI/HICN assignment, coverage start and end dates and beneficiary’s date of birth. Ranked #2 in CEDI’s Top 10 3 Incorrect or missing billing provider NPI and EIN. Ranked #4, #5 and #7 in CEDI’s Top 10 4 Inappropriately dated service dates (start/end dates and pay dates don’t align) Ranked #6 and #8 in CEDI’s Top 10 Sourced from 2019 Publications from CMS and National Government Services Common Electronic Data Interchange (CEDI)

  20. Technology and Workflow Response Errors: • Error Category: Beneficiary Error Code(s): 02125 Error Details: R: Beneficiary date of birth mismatches with the date of birth listed in MARx database.

  21. CMS Common Edit Data Interchange (CEDI) • If you don’t have an error correction system that demystifies the reject reason codes, go to the lookup tool: Click here for a list of reason codes

  22. CMS Common Edit Data Interchange (CEDI) • Access the CEDI spreadsheet for explanations of the errors: • Learn more about the overall submission process: Click here for an explanation Click here to learn more

  23. Join Us for Part 2 of the Webinar • What are your systemic or highest volume errors? • If you have problems tackling these issues, email them to lpouncey@babelhealth.comby tomorrow. • We will review these and provide coaching on how to best resolve them. This will allow you to ask specifics about the challenges you face which most likely are similar to the corrections that your colleagues wrestle with. • If you haven’t signed up for Part 2 of the webinar, please register today by clicking the link below: Click here to register

  24. Thank You! lpouncey@babelhealth.com

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