1. Medicare Diagnosis Code Closure
November 15, 2013
IMPORTANT INFORMATION

2. Correct Coding…More Shopping
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3. Medicare Advantage Gain Sharing
Blue Cross Blue Shield of Michigan and Blue Care Network
are partnering with providers to improve performance for
Blues Medicare Advantage products related to:

Documentation and coding for appropriate risk adjustment

Utilization and cost management

Performance on quality measures (Center for Medicare &
Medicaid Services STARS)
The Blues are doing this through a new Blues Medicare Advantage Gain Sharing program.
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4. Medicare Advantage Gain Sharing
What is Medicare Advantage Gain Sharing?





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New provider incentive program offered by Blue Cross
Blue Shield of Michigan and Blue Care Network
Focuses on BCBSM’s Medicare Plus Blue PPOSM and
BCN Advantage HMO-POSSM
Rewards providers by giving them a share of the
financial “gain” associated with provider performance
improvement
Provides support to enable providers to be successful
Select medical care groups invited to participate in
first phase (Fall 2012 through December 2013)

5. Gain Sharing Model: Step One
Blues Total Premium Revenue
11% Blues Plan Administration*
89% Medical Expense Fund
(underwritten members)
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*Blues Plan
Administration includes:
• BCN Advantage
payment of $1.50 pmpm
to medical care groups
• Medicare Advantage
PPO reimbursement for
provider-directed case
management

6. Gain Sharing Model: Step Two
Medical Expenses
Medical Expense Fund
• All Medical Expenses
• Carve Outs (Rx, behavioral health –
Gain – Providers share gains
Loss – Blues cover all losses
both, lab/DME/dialysis – BCN only)
• BCN Advantage Reinsurance
Gain or Loss
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The group must achieve an
89% or lower medical loss ratio
to participate in the program.

7. Gain Sharing Model: Step Three
Gain Sharing
Education
Criteria (25%)
• Physicians covering 80% of the BCN
Advantage/Medicare Plus Blue PPO membership
• 1 office/billing manager per office covering 80% of
membership
+
Performance
Criteria (10%)
=
Total Possible
(35%)
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• Accurate coding/closing diagnosis code gaps
• Improvement in quality score
• Improvement in readmission rate
• Must achieve both Education Criteria to meet
Education Incentive
• Must achieve Education Incentive to qualify for the
Performance Incentive
• All three of the Performance Criteria must be met
to achieve the Performance Incentive

8. Education Criteria
Education (25 percent of gain) – To achieve, must
complete BOTH 1 and 2.
1.
Primary care physicians who cover at least 80 percent of the Medicare Plus
Blue PPO and BCN Advantage membership attend a Medicare educational
session on:
• The gain sharing model and other physician
incentives
• Risk adjustment, coding and documentation
• STARS measures
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9. Education Criteria
2.
Office staff from offices that cover at least 80 percent of
the Medicare Plus Blue PPO and BCN Advantage
membership attend a similar Medicare educational
session.
• At least one staff person per office (preferably billing
manager or office manager) will receive appropriate
training.
• May be in-person training, webinar, office visit, etc.
‾ You must achieve the Education Incentive to qualify for the
Performance Incentive
‾ If you do not achieve the Education Incentive there is no gain
sharing.
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10. Performance Criteria
Performance (10 percent of gain) – To achieve, must complete all three
performance criteria.
All are scored at the medical care group level.
1.
Accurate coding/closing diagnosis code gaps:
•
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Appropriate diagnoses have been captured for 90 percent of the members
identified or information has been provided that diagnoses expected were
not valid.
– BCN Advantage/Medicare Plus Blue PPO will provide information on
expected diagnoses for all members on Health e-Blue web. Reports
provided through September 2013 comprise the target population.
– A face-to-face visit is required to close a gap
– All gaps must be closed following CDC and CMS standards
− Gaps closed by Inovalon (vendor) will not count for provider

11. Performance Criteria
2. Improvement in quality score:
•
•
Measured separately for both Medicare Plus Blue PPO and BCN
Advantage. Must achieve minimum improvement for each.
•
Improvement measured on sliding scale. Lower scores require more
improvement.
•
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Based on 2012 Composite Quality Score from the Health e-Blue Quality
Summary Report. Improvements must occur before end of 2013.
Measured at the medical care group level – not at individual physician
level.

12. Performance Criteria
3. Improvement in readmission rate:
• Based on 2012 rate. Improvements must occur
before end of 2013.
• Measured for combined population (Medicare Plus
Blue PPO and BCN Advantage)
• Measured at the medical care group level – not at
individual physician level.
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13. What If…
What if one of the following happens?
• The group does not meet the 89% medical loss ratio
• The group does not meet the Education Criteria
Then the group does not qualify for any Gain Sharing
and cannot participate in the Gain Sharing Performance
Criteria.
Primary care physicians from a group that does not
qualify for Gain Sharing are eligible to participate in the
Blues’ Medicare Advantage Diagnosis Closure Incentive
program.
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14. Diagnosis Closure Incentive
Providers cannot participate in both the Gain Sharing Performance Criteria and
the Diagnosis Closure Incentive program. Only one of these incentives can be
earned.
Diagnosis Closure Incentive highlights:
• Measured at the individual physician level
• PCPs with one or more Blues Medicare Advantage patients with at least one
open diagnosis gap identified by the Blues will receive $100 for closing 100%
of the patient’s diagnosis code gaps
• Suspected or historic conditions not accurately documented and coded in the
current year are diagnosis gaps
• Diagnosis gaps will be identified in the new Diagnosis Evaluation report on
Health e-Blue (available by March 2013 and refreshed monthly).
• Gaps identified by the Blues January 1 through September 30, 2013 are
eligible for payment.
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15. Diagnosis Closure Incentive
To earn payment for a patient:
• All the patient’s gaps must be closed in 2013 and reported
to the Blues by January 31, 2014
• The gaps must be closed following a face-to-face visit
• The diagnosed conditions must be addressed at the faceto-face visit
• Coding and documentation must follow CDC and CMS
standards
Gaps closed by Inovalon (vendor)
will not count for the provider
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16. What If…
What if our group could have earned more money in
the Diagnosis Closure Incentive?
• The Blues will calculate the group’s incentive for the Gain
Sharing 10% Performance Criteria and compare it to the
aggregate PCP payment that could have been earned
through the Diagnosis Closure Incentive.
• The Blues will pay the larger of the above two incentives.
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17. What If: Example One
Medical Care Group
Blues Medicare Advantage Value Incentive
Program
Gain Sharing Example (CY 2013)
Additional Criteria MCG Must Meet
Prior to release of any earned surplus for which MCG is eligible
Total Gain (Revenue Less Expense)
MCG Potential Share of Gain
- Base Financial Gain Incentive (25%)
$200,000
$50,000
Physician and Office Staff Training re: Coding, STARS, etc. (Both criteria must be met)
- Supplemental Financial Gain Incentive
(10%) (1)
$20,000
Close Dx Code Gaps, Improvement in Quality Scores, Improvement in Readmission Rate
(All three criteria must be met.)
Potential Gain Available to MCG (2)
$70,000
1. See alternative incentive below.
2. Does not account for any CMS limitation on gain.
Diagnosis Code Gap Closure Incentive Compared to Supplemental Financial Gain
Assume:
- MD gets $100 for each Dx Gap closed.
- 300 members’ Dx gaps closed by MCG
physicians
- Total Dx Gap Closed Incentive Value
Supplemental (10%) Financial Gain Earned by
MCG
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$100
300
$30,000
$20,000
Since the total value of the Closed Dx gaps (i.e. $30,000) is greater than the Supplemental
Financial Gain (i.e. $20,000), BCN will distribute the $30,000 directly to and among the
individual MCG PCPs who closed the gaps. The $20,000 earned by MCG will not be paid.

18. What If… Example Two
ICD-9
Description
HCC
Revenue
ICD-9
Description
HCC
Revenue
250
Diabetes
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$1,307
250.60
Diabetes w/
neurological
manifestations
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$3,291
Polyneuropathy
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$2,637
Total Monthly Premium Revenue to Health Plan
$1,307
Total Monthly Premium Revenue to Health Plan
$5,928
Amount Allocated to the MCG Medical Services Fund
(@ 89%) (1)
$1,163
Amount Allocated to the MCG BCBSM Medicare
Plus Blue PPO Medical Services Fund (@89%)
$5,276
Net Annual Medical Funding to MCG for this BCBSM
Medicare Plus Blue PPO member
$13, 956
Net Annual Medical Funding to MCG for this
BCBSM Medicare Plus Blue PPO member
$63,312
Assume: Annual Expenses for this member
$20,000
Assume: Annual Expenses for this member
$20,000
MCG Medical Service Fund Gain (Loss) for treating
this member.
($6,040)
MCG Medical Service Fund Gain (Loss) for
treating this member
$43,312
MCG Share of Gain (up to 35% if criteria is met)
$15, 159
MCG Share of Gain (up to 35% if criteria is met)
N/A (2)
(1) Same example above applies for BCN Medicare Advantage Value Incentive Program, except for certain
services (and allocated premium) that are “carved-out” and for which MCG is not responsible (e.g. DME, Lab,
Behavioral Health, Outpatient Lab)
(2) MCG is not a financial risk for any losses in this program. BCBSM assumes financial risk for all losses.
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