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Jan Haskell - Mohr

Managed Care: Success with Medicare Advantage

By | Blog

CareOptimize works directly with CareMax Medical Centers, seven full-risk, full-service Medicare Advantage facilities in South Florida. All provide a full spectrum of medical services, including transportation (fleet of 50 vans) and home visits. Because these centers are full-risk, it is imperative CareOptimize monitor each center carefully to ensure CareMax centers remain successful value-based operations. To help do this, they have come up with a suite of templates for physicians and coders to work together at point-of-care not only to make the most beneficial coding decisions, but also to simplify the process.

Managing MA members in comparison to FFS
Medicare Advantage pays a capitated amount per beneficiary and focuses on proactive preventative care and early intervention. Care coordination and innovation are incentivized, and a risk adjustment model is used for patient differences. A comparison chart on cap rates per member per month illustrates how the MA contract rate fluctuates and how it might benefit practices.

Accurate HCC coding provides accurate RAF scores, and that accuracy reflects how well codes have been documented at point-of-care. Most CareMax members are joined with HealthSun, a large Medicare Advantage payer with a coveted 5-star rating from CMS. If HEDIS scores are managed well, HealthSun maintains their 5-star rating, which triggers a 5% bonus in addition to the base per patient per month payment.

By offering providers and payers accurate information, CareOptimize has been able to boost CareMax Medicare Advantage premiums. When Medicare Advantage is managed through accurate HCC coding, etc., even more funds can be generated.

To maximize our systems and take advantage of the Medicare Advantage model, we created a system at point-of-care for physicians to ascertain exactly what they need for accurate coding. This system tracks HCC drop-offs and suspected and overdue codes. The coding review process between provider and coder was streamlined, so coding opportunities would be caught before claim creation. We wanted to back all of this up with aligned workflows in the EHR, so we designed templates to do just that.

The pre-audit process lets providers know there is a set number of patients for the next day. A pre-audit review is generated, which includes suggested codes by coders based on holistic evidence. The physician can see and review the information at point-of-care, including codes, diagnosis descriptions, and status of patient (new or not) in their daily assessments. They can accept the code as is if they feel it’s valid or choose no evidence of disease right there, and go on with their notes. Simplifying the coding process benefits both provider and payer, giving crucial information at point-of-care to be generated, allowing for much more accurate results.

MIPS – What’s New, What Isn’t, and What You Need to Know Now

By | Blog

The MIPS program continues, with all of its trials and triumphs. While many of the parts of the program remain the same, there are some key pieces to keep in mind, so you won’t be left behind in the pursuit of a positive attestation. If you haven’t started on MIPS for 2018, there is still a possibility for reporting and meeting the minimum threshold for the reporting year, especially if you have less than 15 clinicians. It is also important to remember if you haven’t actively engaged in MIPS program and are always waiting to hit that neutral adjustment, scores are publicly available on the Physician Compare website for all to see.

The official attestation period for the 2018 reporting year began on January 2, 2019, and the deadline to send everything in is April 2, 2019. For groups submitting their practitioners as individuals (vs. group), consent does have to be given. A Practice Administrator may give consent on behalf of a group or virtual group, but not for a MIPS-eligible clinician reporting as an individual. MIPS data needs to include all payers for QCDR/Registry/EHR submissions. Medicare only applies exclusively to the Claims and Web interface submissions. The completeness of data must include all payers. For group submissions, data across the entire TIN, including data from non-Eligible Clinicians, must be included.

For 2018 the threshold for data completeness is 60%. Since it is supposed to be an accurate representation of data, you cannot select only the best performing patients. CMS has provided a lot of clarification about this in the last couple of months.

Cost

2018 is the first year practices are being graded on their cost performance. Although this information was provided in 2017, it wasn’t included as part of the overall score. In 2018, there are two measures: TPCC (Total Per Capita Cost – attribution plurality of primary care svcs – specialty-only groups will have patients who fall into this category) and MSPB (Medicare Spending Per Beneficiary – plurality of Part B services billed). Groups where the Eligible Clinician is not attributed any Cost measures will not be calculated a Cost performance score. In 2019, there will be eight new episode-based measures added.

Keep Good Records

It is very important for all to keep good documentation records, and CareOptimize highly recommends having an audit binder. CMS can audit practices up to 6 years after the program year in which you attested, so for PY 2017, you could be audited to 2023. Documentation that should be included in your audit binder includes proof from the registry stating your data was successfully submitted to CMS and a copy of your Security Risk Assessment report that was completed or reviewed, along with the date of completion. The same SRA report can be used and updated year to year. CMS has provided clear breakdowns per measure on what should be included in your audit binder on their website:

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2018-MIPS-Data-Validation-Criteria.zip

For 2018, you do need to be on a 2014 or 2015 certified EHR. If you are looking at an upgrade, such as moving from a 2014 to a 2015 certification, you do need to keep documentation supporting the time period in which you are attesting in your audit binder.

For all measures submitted in the Quality/PI categories, we highly recommend storing that year’s measure details in your audit binder as well as documented workflow used. Include screenshots within the EHR. It doesn’t have to be for specific patients, but you do need to be able to show how the providers are capturing the info. For PI measures, an ONC certified EHR is required to complete the report, which should be included, with numerator and denominator calculations, vendor logo, and timeframe in which you are attesting.

For additional measures within PI reporting, specifically specialized registry reporting and public health measures, it is critical to have documentation from state agencies including emails, screenshots, or receipts showing active engagement.

The CEHRT Bonus in Improvement Activities is a yes/no measure, and you need to include screenshots of the activity being completed for your attestation time period.

What 2019 looks like

The 2019 MIPS period has now started. MIPS 2019 includes two 12-month segments. The timeframe currently posted on the CMS website is October 1, 2017 to September 30, 2018. The second timeframe will be October 1, 2018 to September 30, 2019. Some changes:

  • Quality category now makes up 45%, a lower rate than it previously had, and Cost is 15%.
  • Exceptional performance threshold is now 75 points.
  • CMS is sticking with their decision to have a 2015 CEHRT requirement, which must be in place at least one day during the reporting period.

We can learn a lot from previous years. CMS reported that 93% of MIPS Eligible Clinicians received a positive payment adjustment and 95% avoided a negative adjustment. They have been quite good at predicting trends for the future. For 2018, they predict only 74% of clinicians would earn a score higher than 70% qualifying for the exceptional performance threshold.

Minimum points are increasing from 3 to 15. Distribution of points is also different with the Cost category being implemented and Quality having a smaller percentage. The same trend is expected to continue in 2019, with a minimum point increase to 30 points.

There is an increase in Eligible Clinicians for 2019. The threshold is the same (>$90,000 billed to Medicare, >200 services to Medicare beneficiaries, and > 200 covered professional services), but if you meet one, but not all conditions, you can still opt in for 2019. (Keep in mind once you have opted in, you can’t change it for the applicable performance period.) This will help increase the number of organizations participating and working toward attestation and the possibility of potential positive adjustment.

If you are actively working on 2018 MIPS submission, you should still be looking toward 2019, since there are areas needing work now that will affect your scores down the line. Right now, you should be:

  • Actively reviewing measures (not all will be available for 2019 – make sure to note which will and will not)
  • If you’re working toward that 75-point threshold for 2019 reporting year, education and retraining are extremely important.
  • Understand changes coming and who might benefit, with the additions of new clinicians that can come in as well as the opt-out.
  • Plan your upgrade if you are not already on a 2015 CEHRT.
  • Implement and train on risk adjustment coding. This is where clinicians can actively engage in Cost category to help impact it by simply accurately documenting chronic conditions, which can greatly help improve performance.

Ensuring you keep good records, staying up-to-date on CMS guidelines (www.cms.gov), and getting the help you need will all help you reach you attestation goals. For more information, please contact CareOptimize at info@careoptimize.com, call 855-937-8475, or visit our website www.careoptimize.com.

Capitation and Risk Contracts

By | Webinar | No Comments

The Affordable Care Act requires health plans spend 80-85% of premiums on medical care, which has created a renewed shift towards capitation and risk contracts. This video provides an overview on how to leverage these new contracts and better align physician incentives to keep patients healthy – all while providing opportunities to increase your bottom line.

Medicaid MU3 in 2018

By | Webinar | No Comments

Medicaid MU3 is not going away. In this third iteration of the program, there are some significant changes and requirements to note. This 30-minute webinar takes you through the ins and outs of MU3, giving you tips on how you can actually be successful with the program including:

  • How the number of measures is misleading
  • 2018 compared to 2017
  • Whether or not your EHR measures up

MIPS in the 2018 QPP Final Rule

By | Webinar | No Comments
The 2018 QPP MIPS Final Rule is out. Not only are there some important changes to the structure, but there are also new ways for practices to benefit in MIPS. CareOptimize has pored over the details to bring you what we feel are the most important aspects to ensure your success.
CareOptimize breaks it down for you in this webinar, where, among other things, you’ll learn:
  • Major changes in the 2018 Final Rule
  • How small practices can succeed in MIPS
  • Where you can earn bonus points
  • New thresholds
  • Expanded exemptions

Individual vs. Group Reporting

By | Webinar | No Comments

MIPS allows practices to decide whether providers report as individuals or groups. There are opportunities in making the best choice.
In this webinar, CareOptimize digs deep into the pros and cons of each and what you need to do to ensure you choose the category best for your practice. Topics include:
– The differences between the two categories
– How to determine which is best for you
– What to consider once you’ve chosen
– What the future holds for reporting categories

MIPS’ Final 90-day Countdown

By | Webinar | No Comments

The end of the 2017 MIPS reporting period is coming on fast, and CareOptimize wants to make sure you have everything you need to avoid the penalties and earn your bonuses.

This webinar outlines steps you need to take to be ready for the final 90 days of 2017.
This 30-minute webinar will help you:
– Select measures that score you more points
– Understand how to earn bonus points
– Prepare for MIPS Audits

MIPS: It’s Not Too Late for Your 2017 Bonus

By | Webinar | No Comments

The clock is ticking, but there’s still enough time to secure your MIPS 2017 bonus. This webinar outlines some of the things you can do to ensure you won’t miss out.

In under 30 minutes see how our MIPS Dashboard will help you:
– Track your provider and practice scores per measure
– Select the highest measures to attest
– Uncover patient care gaps to increase scores
– Automate the electronic attestation process