Risk Adjustment User Group

1. Risk Adjustment User Group February 2009

2. Welcome to the FebruaryUser 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 and Notes 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. PAYMENT PROCESS

7. PAYMENT PROCESS • Updates, February 2009 Payment Issues

8. DATA VALIDATION

9. DATA VALIDATION • CY 2007 • Pilot RADV (notified June 20, 2008) • Analyses in progress • Targeted RADV (notified Nov. 10, 2008) • Instructions Packet to be distributed shortly • Selected plans to be notified via email when packet is released • Plans will have 12 weeks to submit medical records • Random RADV • To be implemented

10. DATA VALIDATION • CY 2007 (cont’d) • National Sample (notified December 3, 2008) • Medical record submission deadline is Friday, February 27th. • CMS does not expect to extend the deadline. • As indicated on the December 17th teleconference, it is important that you submit all requested records because: • The data will be used to estimate a Risk Adjustment Part C error rate for the Medicare Advantage program that must be publicly reported; and • Failure to respond may be taken into consideration by CMS when selecting plans for the next cycle of contract-level Risk Adjustment Data Validation.

11. DATA VALIDATION • CY 2007 (cont’d) • Submit your RADV-related questions: • To Ann Marshall on the RADV team at ann.marshall@cms.hhs.gov • By close of business the Friday before the User Group call • Contact Health Management Solutions (HMS) for technical assistance and questions that require an immediate response relating to medical record submission.

12. DATA VALIDATION • Signature Stamp Policy • Stamped signatures are no longer acceptable for provider documentation (Medicare Program Integrity Manual, Transmittal 248, Change Request 5971, 5550). CMS implemented this policy retroactively. • For purposes of Part C Risk Adjustment Data Validation, we are applying an alternative implementation date. Stamped signatures will no longer be acceptable on medical records with dates of service on or after January 1, 2009. Medical records with dates of service in CY 2009 will impact CY 2010 payments.

13. DATA VALIDATION • Medical Record Submission • CMS’ contractor received several packages that did not meet our criteria. • Reminders: • Complete only one coversheet for each enrollee CMS-HCC. • Do not submit multiple copies of the same medical record. • Do not intersperse coversheets with unrelated medical record dates of service.

14. DATA VALIDATION • Medical Record Submission • Do not highlight material in the medical record to draw attention to it; upon contractor scanning, it becomes illegible text. • Submit coversheets and medical records to Melissa Sayre as directed in your RADV Instructions. (Note fax number is 1-866-779-8488).

15. DATA VALIDATION • Submission Security Requirements • If submitting medical records via: • Virtual Private Network (VPN), contact HMS as soon as possible to • Obtain VPN User ID and password • Conduct an IT-to-IT teleconference to address system-to-system differences (e.g., firewalls) • Electronic media (USB, CD, DVD) • Encrypt files • If sending accompanying hardcopy PII and/or PHI, send via USPS certified mail with return receipt • If sending only electronic media (i.e., no hardcopy PII and/or PHI), may send via commercial traceable carrier

16. DATA VALIDATION • Submission Security Requirements (cont’d) • If submitting medical records via: • Hardcopy • Use tamper-proof packaging • Mail via USPS certified mail with return receipt • Fax • Coordinate a “test” with HMS in advance of submitting PII and/or PHI • Never submit PII and/or PHI by e-mail

17. OPERATIONS UPDATES

18. OPERATIONS: General Information • There are 57 new plans for 2009. CSSC encourages new plans to send in the necessary EDI Agreement package if they have not done so thus far. CMS expects new plans to begin submitting data by the end of March.

19. Operations: Top most Front-End Errors AAA Record: • 113 – File name duplicates another File accepted within last 12 months. BBB Record: • 202 – Missing or invalid sequence number on BBB Record. CCC Record: • 311 - At least one diagnosis cluster required on transaction. YYY Record: • 263 – Plan Number does not match Plan Number in BBB Record. ZZZ Record: • 163 – The File ID does not match File ID on AAA Record.

20. Operations: Top most RAPS Errors Month of January 2009 CCC Record: • 501 – (Informational Edit) Valid diagnosis but not a relevant diagnosis for risk adjustment during this service period. (This represents 62.04% of the total errors.) • 410 – Beneficiary is not enrolled in Plan on or after Service From Date. (This represents 10.47% of the total errors.) • 408 – Service From date is not within MA enrollment period. (This represents 9.37% of the total errors.) • 409 – Service Through date is not within MA enrollment period. (This represents 8.65% of the total errors.) • 502 – Diagnosis cluster was accepted but not stored. A diagnosis cluster with the same attributes is already stored in the RAPS database. (This represents 2.94% of the total errors/)

21. Operations: Most Common Question • When will the Sweep Occur? • CMS does not release the sweep date, until the sweep is completed. However, CMS informs plans of the final submission date and for 2007 data the final submission is January 31, 2009 for guaranteed inclusion in the risk adjustment run.

22. TECHNICAL ASSISTANCE UPDATES

23. TECHNICAL ASSISTANCE UPDATES Next User Group Meeting March 18, 2009

24. QUESTIONS & ANSWERS

25. CLOSING

26. 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 • Lateefah Hughes (RADV) lateefah.hughes@cms.hhs.gov • LTC www.tarsc.info • CSSC www.csscoperations.com