1. March
21,
2014
Commercial
Market
&
Health
Insurance
Exchanges

2. ©2013
! Increased
to
4.24
M
thru
Feb
! 3.3M
Through
Jan
> 38%
State
Based
Marketplace:
1.6M
> 62%
Federally
Facilitated
Marketplace:
2.6M
! 25%
ages
18-­‐34
(young
invincibles)
! 45%
male;
55%
female
Overall
Enrollment

3. ©2013
3
Enrollment
by
Metal
Level
Bronze
Silver
Gold
PlaSnum
Catastrophic
18%
63%
11%
6%
1%
Bronze
Silver
Gold
PlaSnum
Catastrophic
15%
66%
10%
5%
4%
Overall
Enrollment
by
Metal
Level
Young
Invincibles
by
Metal
Level

4. ©2013
! Financial
Assistance
> 83%
of
Marketplace
enrollees
are
receiving
financial
assistance
– 81%
State
Based;
85%
Federal
Facilitated
> 74%
with
financial
assistance
selected
a
Silver
plan
! Without
Financial
Assistance
> 26%
Silver
plan
> 30%
Bronze
plan
Marketplace
&
Financial
Assistance

5. ©2013
! Marketplace
closes
! Off-­‐Exchange
enrollment
! Small
group
roll-­‐in
> Adding
to
the
risk
pool
> Mandate
postponed
&
revised
again
! SHOP
making
it’s
début
! Looking
to
next
year
> TransiMonal
policies
conMnue
> Fall
ElecMons
> Open
Enrollment:
Nov
15
through
Feb
15
The
Rest
of
the
Enrollment
Story

6. ©2013
Regulatory
Requirements
6

7. ©2013
7
ComparaSve
Summary
of
Risk
Adjustment
Models
MEDICAID
COMMERCIAL
MEDICARE
Funding
Budget
Plan
Revenue
Impact
Risk
Model
New
Enrollee
Timing
Payment
Structure
Risk
Pools
Scoring
Requirement
Submission
Protocol
Score
Timing
Audits
State
budget
neutral;
Affects
future
reimbursement
ACG(4);
CRG(1);
CDPS(18);
MRX(6);
ERG(1);
DxCG(1)
Varies
3-­‐6
mos
ProspecMve;
Aggregate
Varies
by
aid
category
Diagnosis
codes;
pharmacy
Varies
by
state
Annual;
Semi-­‐annual
Limited
Annual
Annual
by
April
30
CMS
XML
format
on
Edge
server
Paid
claims
diagnosis
codes
+
procedures
codes
Community;
metal
level
Concurrent;
aggregate
Immediate
CMS
Commercial
HCC;
except
MA
Funds
transfer
between
plans
Government
unappropriated;
Plans
subsidize
one
another
Government
funded;
Balanced
to
FFS
No
downside
to
underesMmate
RAF
CMS
HCC/Rx
HCC;
ESRD
12
mos
ProspecMve;
Individual
Community;
InsMtuMonal,
ESRD
Diagnosis
codes
Jan/Mar/Sept
Sporadic
RADV
RAPS
submission;
Encounters
soon
ICD-­‐10
Ouch!

8. ©2013
8
ACA
–
MA
RADV
Comparison
Commercial
ACA
RADV
Medicare
MA
RADV
Commercial
ACA
RADV
Medicare
MA
RADV
Audit
EnSSes
• MulMple
independent
IVA’s
may
be
cerMfied
• SVA
may
be
CMS
or
designee
CMS;
contracted
to
HMS
DocumentaSon
Enrollment,
medical
record,
claims
Medical
record
only
Audited
data
All
risk
adjusMng
data:
HCC
+
demographics
+
claims
(poss)
HCC
only
DocumentaSon
per
enrollee
• IVA
requires
yet
unspecified
qty
of
records
per
enrollee;
• SVA
uses
IVA
docs,
no
addiMonal
records
submiied
Up
to
5
in
rank
order
of
best
Sample
Data
Criteria
• De-­‐idenMfied
Edge
data
• 1/3
w/o
HCC’s
CMS
data;
12
mos
MA
enrollment
Sample
Size
200
per
issuer
per
state
for
2014-­‐15
201
enrollees
Sample
• 9
strata:
age
bands
&
risk
level;
1
strata
wi/o
HCC’s
• Uses
issuer
actual
data
• 3
risk
levels
•
Uses
issuer
actual
data
DOS/Provider
Match
Appears
to
be
a
criteria
Not
required
CalculaSng
error
rate
• Error
=
any
change
in
risk
score
• By
the
IVA
• Finalized
by
the
SVA:
IVA/SVA
comparison
Issuer
submits
docs
to
CMS,
CMS
calculates
ApplicaSon
of
Error
rate
• Applied
to
each
issuer’s
plan
in
the
state;
• ProspecMve
year’s
funds
transfer
formula
adjusted;
Individual
at
issuer
level
Non-­‐
compliance
• Default
error
rate
(highest
poss)
• Civil
penalMes:
issuer
&
IVA
• Fraud
prosecuMon
Funding
Issuer
funds
IVA
CMS

9. ©2013
! Select
one
or
more
IVA’s
by
March
31
each
year
! Validate
IVA
qualificaSons:
cerSfied
coders,
HIPAA,
! Akest
to
the
absence
of
conflict
of
interest
> Issuer
financial
ownership,
material
interest,
board/
leadership,
family
> IVA
has
no
role
in
any
“relevant
internal
controls
or
serve
in
an
advisory
capacity
related
to
the
RADV
> Obtain
equivalent
aiestaMon
from
the
vendor
! Fund
the
IVA
audit
! ParScipate
in
mulSple
states
if
applicable
! Cross
walk
de-­‐idenSfied
sample
to
enrollee
data,
source
enrollment
and
medical
records
! Securely
provide
data
to
IVA
! Establish
and
manage
IVA
Smeframes
9
Issuer
Requirements

10. ©2013
10
RADV
&
Funds
Transfer
Timing
! Two-­‐year
cycle
! ProspecSve
adjustment
to
funds
transfer
Yr Operations Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec
2014 2014
Benefit
Year
2015
Benefit
Year
2015
Data
Activities
Rec
Funds
Chg/Pay
2014
data
2015
Audit
Activities
Submit
IVA
to
CMS
Receive
2014
Sample
Begin
2014
SVA
2016
Benefit
Year
2016
Data
Activites
Rec
Funds
Chg/Pay
2015
Adj
for
2014
RADV
Submit
2015
IVA
to
CMS
Receive
2015
Sample
Begin
2015
SVA
2014
Benefit
Year
2016
Benefit
Year
IVA
2015
Data:
results
to
CMS
Dec
1
2015
2016
2016
Audit
Activities
Finalize
Edge
server
2014
data
IVA
2014
Data:
results
to
CMS
Dec
1
SVA
2014
Data
SVA
2014
findings
&
appeals
Finalize
Edge
server
2015
data
2015
Benefit
Year

11. ©2013
! Data
Accuracy
ImperaSve
> Validates
ALL
data
related
to
the
risk
score
calculaMon:
demographics,
health
status
and
possible
enrollment
and
claims
> De-­‐idenMfied
sample
requires
reliable
common
files
> DOS
and
provider
matching
–
precision
claims
processing
> OperaMonal
planning:
correct
all
errors
! IVA
documentaSon
selecSon
process
cannot
be
underesSmated
! Financial
projecSons
for
funds
transfer
formula
! Plan
for
addiSonal
scruSny
> Enrollment
> Subsidies
> False
Claims
Act
prosecuMon
11
ACA-­‐RADV
Process
CauSons

12. ©2013
! Risk
Adjustment
> Focus
on
aspects
not
included
in
RADV;
plan
type
is
risk
adjusMng,
renewal
data,
plan
size
! Reinsurance
> Targeted
contributors:
Enrollment
counts,
covered
lives
and
payments
> Targeted
issuers:
plan
eligibility,
claims
(Edge
data)
! Risk
Corridor
> Robust
audit
(protecMng
federal
funds)
aligned
with
MLR
audit
> ValidaMon
check
for
enrollment
and
premiums
on
the
Edge
server
> Targeted
contributors
(est
1%);
Targeted
issuers
(est
5%)
12
Other
Audits

13. ©2013
13
Audit
OperaSons
Checklist
FuncSon
Risk
&
RADV
Vulnerability
OperaSonal
ConsideraSons
Edge
Server
Data
• Correct
all
errors
• De-­‐idenMficaMon
crosswalk
• Claim-­‐DOS
Match
Create
pre-­‐validaMon
rules
Enrollment
• Availability
of
data
• Grace
period
• Plan
changes
Include
enrollment
audit
with
retrospecMve
process
Claims
Systems
• Custom
business
rules
• Void/replace
process;
parMal
denials
• Interim
bills
• ICD-­‐10
conversion
Incorporate
into
Edge
server
pre-­‐
validaMon
rules
Risk
Adjustment
• Enrollment
Mming
• ICD-­‐10
transiMon
• Supplemental
data
submission
Assume
assessments
and
retro
charts
are
audited;
delete
codes
&
linked
supplemental
data
Providers
• ICD-­‐10
TransiMon
• Chart
retrieval
volume
• DocumentaMon
accuracy
IncenMves
for
chart
access;
Provider
panel
evaluaMon
Finance
• Audit
funding
• Funds
transfer
projecMons
Crack
open
the
piggy
bank
Compliance
• Audit
staffing
Evaluate
internal
resources

14. ©2013
! Following
established
Edge
server
communicaSons
with
HHS,
issuers
are
expected
to
submit
quarterly:
“complete
and
current
enrollment
file
and
a
good
faith
effort
for
accurate
and
current
claims
files”
> TransacMonal
process
report—issuer
required
to
correct
or
accept
the
rejecMon
> CMS
expects
issuers
to
proacMvely
idenMfy
and
correct
risk
adjusMng
claims
! CMS
provided
interim
report
> Preliminary
risk
scores
&
aggregated
claims
for
reinsurance
! Issuer
response
required
> Interim
report
30
days;
> 15
days
for
final
report
issued
before
June
30
14
Distributed
Data
Requirements
Clarified

15. ©2013
! Default
risk
adjustment
charge;
several
opSons
proposed
> Failure
to
set
up
an
Edge
server
> Inadequate
Data
> PMPM
based
on
a
fixed
%
of
the
state-­‐wide
average
premium
and
enrollment
based
on
MLR
or
risk
corridor
or
“other”
! Supplemental
data
submission
> Delete
codes
> Linked
to
a
paid
claim
15
AddiSonal
Distributed
Data
Requirements

16. ©2013
! Member
scoring
occurs
at
the
issuer
level;
> risk
scores
follow
the
member
within
the
issuer
> Requires
adequate
re-­‐idenMficaMon
process
> Not
linked
across
issuers
owned
by
the
same
company
! DOS
clarificaSon:
must
match
the
enrollment
period
! Grace
period
claims
will
only
be
counted
if
not
retro
terminated
> Create
an
error
workflow
for
this
process
! No
change
to
the
geographic
cost
factor
calculaSon
! Small
group
counSng
methodology
consistent
with
SHOP
methodology
! Small
groups
that
become
large
can
conMnue
in
risk
adjustment
16
Funds
Transfer
Formula
ClarificaSons

17. ©2013
TargeSng
Strategy

18. ©2013
! Beyond
Risk
Adjustment:
RetenSon
and
Care
Management
! Historically
reported
diagnoses
is
NOT
enough
! High
confidence
level
important
to
minimize
provider
&
member
abrasion
> Transparent
model
that
is
edited
based
on
results
! Supplemental
Data
> External
data
sources
based
on
enrollee
demographics
! Pharmacy
Data
> 177,000
+
NDC’s
requires
consolidaMon
to
generic
product
indicator
! Client
Data
AddiSons
> Self-­‐reported
condiMons
(health
survey)
> Third
party
data,
such
as
underwriMng
data
> Prior
AuthorizaMon
data;
Care
Management
data
! Overall
model
modifiers
> Prevalence
rates
> Chronicity
> Code
Recoverability;
Provider
coding
paierns
18
TargeSng
AnalyScs:
Data
Sources

19. ©2013
AdjusSng
PrioriSes
for
Prevalence
HCC
HCC
Dx
Group
Label
Weight
Exp
Value
HCC
HCC
Dx
Group
Label
Weight
Exp
Value
HDX21 Hematological
Disorders 49.8 149.5 HDX21 Hematological
Disorders 49.8 149.5
HDX39 Severe
Respiratory
Conditions 40.1 40.1 HDX05 Cancer 25.2 75.5
HDX54 Renal
Disease 37.7 37.7 HDX39 Severe
Respiratory
Conditions 40.1 40.1
HDX40 Heart
Assistive
Device/Artificial
Heart
(G14)33.7 33.7 HDX11 Peritonitis/Gastrointestinal
Perforation/Necrotizing13.1 39.4
HDX05 Cancer 25.2 75.5 HDX54 Renal
Disease 37.7 37.7
HDX07 Protein-­‐Calorie
Malnutrition 14.8 14.8 HDX23 Addiction
(G09) 3.8 34.0
HDX02 Septicemia,
Sepsis,
Systemic
Inflammatory
Response
Syndrome/Shock13.7 13.7 HDX40 Heart
Assistive
Device/Artificial
Heart
(G14)33.7 33.7
HDX11 Peritonitis/Gastrointestinal
Perforation/Necrotizing
Enterocolitis13.1 39.4 HDX04 Opportunistic
Infections 9.7 29.0
HDX48 Arterial
Disease 11.9 11.9 HDX53 Aspiration
and
Specified
Bacterial
Pneumonias
and9.1 27.2
HDX42 Ischemic
Heart
Disease 11.9 11.9 HDX15 Arthropathy
/
Osteopathy
(G03) 7.9 23.6

20. ©2013
20
Commercial
Risk
Adjustment
IntervenSon
Strategy
• Outreach
&
Survey
• Targeted
Appointment
Assistance
• Outreach
&
Survey
–
mulSple
akempts
• Appointment
Assistance
&
IncenSve
• Retro
Chart
Review
• Outreach
condiSon-­‐based
• Appointment
Assistance
&
IncenSve
• Concurrent
Chart
Review
• Home
Assessment
(?)
• Outreach
&
Survey
• Outreach
&
Survey
–
mulSple
akempts
• Appointment
Assistance
• Outreach
condiSon-­‐based
• Appointment
Assistance
&
IncenSve
• Retro
Chart
Review
• Outreach
&
Survey
• Outreach
&
Survey
• Outreach
condiSon-­‐based
• Appointment
Assistance
&
IncenSve
Risk
Score
Gap
Low
Med
High
PredicSve
AnalyScs
Confidence
Level
Low
Med
High
Supplemental
Rx
Prevalence
&
Survey
Messaging
Variables
• Chronic
condiMon
• Subsidy
• Metal
Level
• New
to
the
Plan
4%
12%
30%
55%
50%
of
total
populaSon

21. ©2013
! High
HCC
scores
create
economic
value
when
the
cost
of
care
is
managed
! Data
accuracy
required:
enrollment,
claims,
edge
server
! Enrollees
with
high
costs
and
missed
HCC’s
cause
economic
loss
! ACA-­‐RADV
has
material
impact
> Provider
documentaMon
and
claims
processing
is
criMcal
> Expect
annual
adjustments
! ICD-­‐10
! Increased
reliance
on
the
provider
> Provider
claims
processing—for
risk
adjustment
and
audit
> Provider
documentaMon—for
audit
purposes
> Provider
coding
errors—affects
risk
adjustment
and
audits
Managing
the
Funds
Transfer
Formula
21

22. ©2013
! Managing
mulSple
risk
models:
Medicare,
Medicaid,
Commercial
! Market
changes
> Medicare,
Medicaid,
Commercial
volume
increases
> New
commercial
market
risk
adjustment
documentaMon
requirements
! Limited
resources
! EMR
impact
to
billing
and
risk
scores
! TransiSon
to
ICD-­‐10
will
> increase
edits/denials
> decrease
claim
volume
and
coding
accuracy
! ICD-­‐10
for
Risk
Adjustment
22
Provider
ConsideraSons

23. ©2013
! Edge
server
data
transformaSon
> Adjust
infrastructure
to
capture
new
required
data
elements
> Assess
impact
of
data
erosion
and
errors
> Evaluate
custom
claims
adjudicaMon
business
rules
! Outreach
Campaigns
> Cross
funcMonal
outreach
strategy:
risk
adjustment,
retenMon,
uMlizaMon
! Analyze
historical
Commercial
PopulaSon
> Begin
looking
for
data
gaps
! Provider
financial
impact
planning
&
Engagement
Strategy
> Provider
panel
analysis
! ICD-­‐10
risk
adjustment
planning
! Establish
RADV
compliance
and
operaSons
teams
! Reinsurance
claims
monitoring
! Prepare
care
management
teams
based
on
new
plan
benefits
and
populaSon
demographics
Take
AcSon
Now
23

24. 877.461.0415
|
Info@AltegraHealth.com
|
AltegraHealth.com
Discussion