CMS RADV Extrapolation Methodology: In English

Size: px
Start display at page:

Download "CMS RADV Extrapolation Methodology: In English"

Transcription

1 CMS RADV Extrapolation Methodology: In English Presented by: Kim Browning, CHRS,CHC, PMP Executive Vice President, Cognisight, LLC & Kathy McGuire, BSN,MS Rochester General Health System Senior Vice President of Long Term Care and Senior Services October, 2013

2 Objectives Quick Overview of Risk Adjustment Data Validation (RADV) Examples of actual Risk Adjustment Data Validation (RADV)audits Understand how CMS will calculate new Risk Adjustment Data Validation (RADV) payment methodology What will CMS do and how will they do it Provide practical ways to use today s learning and apply to your internal controls/internal audit Cognisight, LLC

3 Risk Adjustment Data Validation An annual audit, conducted by CMS to verify plans risk adjustment payments Two types of audits: National Several plans asked to submit risk adjustment documentation to CMS for a very small sample To date, no financial implications Targeted 30 plans a year; full audit Financial implications New validation payment methodology being applied

4 Risk Adjustment Data Validation 101 Risk Adjustment Flow 4 PACE Plan Receive Risk Adjustment Payment from CMS Provide Care Submit RAPS/EDPS to CMS Mine Documentation for Risk Adjustments

5 Risk Adjustment Data Validation 101 Risk Adjustment Data Validation Flow CMS 5 Risk Adjustment Validation Payment Methodology Targeted RADV Risk Adjustment Substantiation CMS Determines Sample from RAPS/EDPS Submit medical records to CMS

6 Results From Risk Adjustment Data Validation Background Using Cognisight clients as the population None of Cognisight PACE plans have been selected Cognisight Medicare Advantage clients selected for National RADV only Results represents client & Cognisight submits 81% client submits, 19% Cognisight submits 6

7 Results From Risk Adjustment Data Validation Medicare Advantage (National RADV) Out of 20 Cognisight serviced health plans: 7 total plans selected by CMS for 10 distinct audits 1 plan selected 2 consecutive years 1 plan selected 2 out of 4 years 1 plan selected but conducted internally, no details to share 14 affected members with a total of 43 HCCs 7

8 Results From Risk Adjustment Data Validation Medicare Advantage (National RADV) 8 Members HCCs Ranges Average 2 6 Mode 1 2* % substantiated HCCs % % non-substantiated HCCs % % unsure HCCs %** Only 2 members had 2 HCCs ** 3 were Cognisight finds

9 Results From Risk Adjustment Data Validation Medicare Advantage (National RADV) Common HCCs Body System HCCs Outcome 9 Cardio-Vascular 105 (5x) 92 (2x) 80 (4x) 79 (2x) all substantiated all substantiated 1 unsure 1 unsure Respiratory 108 (4x) all substantiated Neuro-Ophthal & Psych 71 (2x) 55 (2x) both substantiated both unsure Neoplasms 10 (2x) both unsubstantiated Genitourinary 131 (2x) both substantiated Endocrine 15 (2x) both substantiated 7 total plans; 10 distinct audits; 81% client submits; 19% Cognisight submits

10 Results From Risk Adjustment Data Validation 10 Medicare Advantage (National RADV) 13 Single HCCs Body System HCCs Outcome Cardio-Vascular Digestive unsubstantiated substantiated unsubstantiated substantiated Neuro-Ophthal & Psych 69 unsubstantiated Major Organ Transplants 176 unsubstantiated Neoplasms 7 8 Endocrine unsubstantiated substantiated substantiated substantiated unsubstantiated Infections & Parasitic 27 unsubstantiated Injury & Poisoning 161 unsubstantiated 7 total plans; 10 distinct audits; 81% client submits; 19% Cognisight submits

11 Results From Risk Adjustment Data Validation Medicare Advantage (National RADV) Unsubstantiated Reasons History of vs. active Incorrect ICD-9 or V Code Ineligible provider 11 Handout with ICD-9 & HCC 7 total plans; 10 distinct audits; 81% client submits; 19% Cognisight submits

12 Results From Risk Adjustment Data Validation SCAN Health Targeted RADV 12 Permission to share by T. Pham, SCAN Health

13 Extrapolation Methodology Background This methodology applies to Audits conducted on Payment Year 2011 (dates of service 2010) PY First Year for extrapolated estimates Sampling occurs after close of final reconciliation for payment year under audit CMS goal is to address: The national payment error rate for MA program Quality of risk adjusted data submitted for payment by MA Organizations Cognisight, LLC

14 Extrapolation Methodology Background 14 Easy to Understand, Right? 2013 Cognisight, LLC

15 Extrapolation Methodology Background Sampling and Stratification CMS selects a sample of beneficiaries from each MA Contract Enrollee-based stratification RADV eligible enrollees ranked from lowest to highest based on community score 15 Three groups highest risk scores, lowest scores and the middle stratum 2013 Cognisight, LLC

16 slide 6 Extrapolation Methodology Background Importance of Stratification Random sampling has high risk of not representing your population and or performance Stratification consists of dividing the population into subsets (called strata) within each of which an independent sample is selected. Stratification reduces some of the variability Cognisight, LLC

17 Extrapolation Methodology Background Sample Size CMS performs sample selection of 201 enrollees for medical record review 17 Of the 201 sample size, 67 will be randomly selected from each group or stratum Contracts with fewer than 1000 RADV-eligible enrollees CMS will adjust sample size to lower than Cognisight, LLC

18 To Simplify Think of RADV Extrapolation as a Roadmap #1 Know RADV eligibles #2 Know total CMS payment #3 Divide RADV sample into thirds (High/Med/Low stratum) #4 Determine weighting for each stratum #5 Determine estimated weighted payment error (Point Estimate) #6 Determine Standard Error #7 Calculate Confidence Interval #8 Determine upper and lower bound amounts by adding/subtracting the Confidence Interval to the Point Estimate #9 Take lower bound amount and apply FFS adjuster Cognisight, LLC Slide 21

19 RADV EXTRAPOLATION EXAMPLE # RISK SCORE STRATA MA PAYMENT Hypothetical MA Pymt. Variance Weighted Payment error Mean of Stratum Deviation Deviation Squared 19 Variance (div by 67-1) TOP 3RD $ 47, $ 47, $ - $ - $ 1, $ (1,915.67) $ 3,669, TOP 3RD $ 47, , , (1,915.67) 3,669, TOP 3RD $ 38, , (1,947.76) (9,690.11) 1, (3,863.43) 14,926, TOP 3RD $ 34, , , (1,915.67) 3,669, TOP 3RD $ 33, , , (1,915.67) 3,669, TOP 3RD $ 12, , , (1,915.67) 3,669, TOP 3RD $ 12, , , (1,915.67) 3,669, TOP 3RD $ 12, , , (1,915.67) 3,669, TOP 3RD $ 12, , , , , ,042, TOP 3RD $ 11, , $ - $ 1, $ (1,915.67) $ 3,669, $ 1,309, $ 1,181, $ 128, $ 638, $ 128, $ 0.00 $ 1,989,292, ,140, Error % 9.80% Enrollee Weight Weighted Enrollee Payment Error 4 $ 638, MIDDLE 3RD $ 11, $ 11, $ - $ - $ $ (894.25) $ 799, MIDDLE 3RD $ 11, , (894.25) 799, MIDDLE 3RD $ 11, , (894.25) 799, MIDDLE 3RD $ 11, , (3,725.76) (18,535.66) (4,620.01) 21,344, MIDDLE 3RD $ 10, , (894.25) 799, MIDDLE 3RD $ 6, , , , ,729, MIDDLE 3RD $ 6, , (894.25) 799, MIDDLE 3RD $ 6, , (894.25) 799, MIDDLE 3RD $ 6, , (894.25) 799, MIDDLE 3RD $ 6, , $ - $ $ (894.25) $ 799, $ 580, $ 520, $ 59, $ 298, $ 59, $ 0.00 $ 482,885, ,316, Error % 10.32% Enrollee Weight Weighted Enrollee Payment Error $ 298, Nh=1000 Roadmap Summary BOTTOM 3RD $ 6, $ 6, $ - $ - $ $ (373.75) $ 139, BOTTOM 3RD $ 6, , (373.75) 139, BOTTOM 3RD $ 6, , (373.75) 139, BOTTOM 3RD $ 5, , (373.75) 139, BOTTOM 3RD $ 5, , , , ,683, BOTTOM 3RD $ 5, , (1,707.40) (8,494.32) (2,081.15) 4,331, BOTTOM 3RD $ 1, , (373.75) 139, BOTTOM 3RD $ 1, , (373.75) 139, BOTTOM 3RD $ 1, , (373.75) 139, BOTTOM 3RD $ 1, , $ - $ $ (373.75) $ 139, $ 252, $ 227, $ 25, $ 124, $ 25, $ (0.00) $ 100,460, ,522, Error % 9.93% Enrollee Weight Weighted Enrollee Payment Error $ 124, Total Estimated Payment Error 64,513,183,122 2 Strata Total $ 2,142, $ 1,929, $ 213, $ 1,061, Standard Error (SE) (Sq of PE) 253, Total CMS Pymt $ 10,800,000 Sample Population (Extrapolated) Confidence Interval CI (2.575*SE) $ 654, Average Error % 10% 10% POINT ESTIMATE (PE) $ 1,061, PE + Confidence Interval $ 1,715, PE - Confidence Interval $ 407, Lower Bound CI 407, Payment Recovery Amount subject to FFS Used monthly payment amounts to simplify example 1 1 RADV Eligibles 2 Total CMS Pymt 3 Divide sample into 3 stratum 4 Weight the stratum 5 Point Estimate 6 Standard Error 7 Confidence Interval 8 Upper & Lower bounds 9 Lower + FFS adjuster Cognisight, LLC

20 Correlation to Internal Controls/Audit Give consideration to refining internal controls and audit strategies to accommodate RADV Like you do with Quality, Falls, etc.,focus on your highest risks 20 Focus on Top 1/3 Paid Used approach with a PACE plan in the North East 2013 Cognisight, LLC Slide 23

21 Impact of Risk Verification PACE Plan, 400 Members, $11M Annual Plan Revenue 21 10% Error Rate 20% Error Rate Payment Recovery $0.41M $1.16M Post 100% Review of Top Third Stratum Payment Recovery $0.11M $0.41M Error Rate reduced 4% 8% Disclaimer: This example assumes equal distribution of error in each of the sample stratum Cognisight, LLC

22 Contact Information If you have questions or would like more information, please contact: Kim Browning, Executive Vice President Chetna Chandrakala, Vice President To obtain a more detailed version of the step-by-step portion of the presentation, please contact: 22 Steve Coan, Vice President, Business Development scoan@cognisight.com Cognisight, LLC

Risk Adjustment 101: Health-Based Payment Adjustment Methodology

Risk Adjustment 101: Health-Based Payment Adjustment Methodology Risk Adjustment 101: Health-Based Payment Adjustment Methodology Presented by: Kim Browning, CHC, PMP, CHRS Executive Vice President, Cognisight, LLC Tara Swenson Attorney, Mintz, Levin, Cohn, Ferris,

More information

Using encounter data for risk adjustment in Medicare Advantage. Andy Johnson and Dan Zabinski April 7, 2016

Using encounter data for risk adjustment in Medicare Advantage. Andy Johnson and Dan Zabinski April 7, 2016 Using encounter data for risk adjustment in Medicare Advantage Andy Johnson and Dan Zabinski April 7, 2016 Presentation outline Medicare Advantage (MA) risk adjustment overview & current use of FFS cost

More information

Risk Adjustment ABC s

Risk Adjustment ABC s Medicare Advantage Risk Adjustment and Coding Academy Coding Risk Adjustment Documentation Training Risk Adjustment ABC s What is Risk Adjustment? Risk adjustment is the process by which the Medicare &

More information

INTRODUCTION. 7 DISCUSSION AND ONGOING RESEARCH.. 29 ACKNOWLEDGEMENTS... 30 ENDNOTES.. 31

INTRODUCTION. 7 DISCUSSION AND ONGOING RESEARCH.. 29 ACKNOWLEDGEMENTS... 30 ENDNOTES.. 31 May 2010 Working Paper: Using State Hospital Discharge Data to Compare Readmission Rates in Medicare Advantage and Medicare s Traditional Fee-for-Service Program TABLE OF CONTENTS SUMMARY 1 INTRODUCTION.

More information

INTRODUCTION BACKGROUND Skilled Nursing Facilities A SNF is an institution primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care and

More information

MCP Audit Newsletter

MCP Audit Newsletter Government of Newfoundland and Labrador Department of Health and Community Services MCP Audit Newsletter October 2006 06-07 TO: ALL FEE-FOR-SERVICE PHYSICIANS New Audit Process to be Piloted Claims Monitoring

More information

Medicare Advantage coding intensity and health risk assessments. Andy Johnson October 8, 2015

Medicare Advantage coding intensity and health risk assessments. Andy Johnson October 8, 2015 Medicare Advantage coding intensity and health risk assessments Andy Johnson October 8, 2015 Presentation outline Health risk assessments (HRAs) Medicare Advantage (MA) risk adjustment Impact of HRAs on

More information

Risk Adjustment in the Medicare ACO Shared Savings Program

Risk Adjustment in the Medicare ACO Shared Savings Program Risk Adjustment in the Medicare ACO Shared Savings Program Presented by: John Kautter Presented at: AcademyHealth Conference Baltimore, MD June 23-25, 2013 RTI International is a trade name of Research

More information

Risk Adjustment Data Validation of Payments Made to PacifiCare of Texas for Calendar Year 2007 (Contract Number H4590) (A-06-09-00012)

Risk Adjustment Data Validation of Payments Made to PacifiCare of Texas for Calendar Year 2007 (Contract Number H4590) (A-06-09-00012) May 29, 2012 TO: Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services FROM: /Daniel R. Levinson/ Inspector General SUBJECT: Risk Adjustment Data Validation of Payments Made to

More information

RISK ADJUSTMENT DATA VALIDATION

RISK ADJUSTMENT DATA VALIDATION Department of Health and Human Services OFFICE OF INSPECTOR GENERAL RISK ADJUSTMENT DATA VALIDATION OF PAYMENTS MADE TO EXCELLUS HEALTH PLAN, INC., FOR CALENDAR YEAR 2007 (CONTRACT NUMBER H3351) Inquiries

More information

Improving risk adjustment in the Medicare program

Improving risk adjustment in the Medicare program C h a p t e r2 Improving risk adjustment in the Medicare program C H A P T E R 2 Improving risk adjustment in the Medicare program Chapter summary In this chapter Health plans that participate in the

More information

ACOs may elect Track 2 without completing a prior agreement period under a one-sided model

ACOs may elect Track 2 without completing a prior agreement period under a one-sided model Financial and Regulatory Parameters for MSSP Risk Tracks in ACO Learning Network Comments and the blue box indicates LN different from ; red text indicates change from and/or LN on Transition to Two-Sided

More information

Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population

Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population Geneva Association 10th Health and Aging Conference Insuring the Health of an Aging Population November 18, 2013 Diana Dennett EVP, Global Issues and Counsel America s Health Insurance Plans (AHIP) America

More information

Northumberland Knowledge

Northumberland Knowledge Northumberland Knowledge Know Guide How to Analyse Data - November 2012 - This page has been left blank 2 About this guide The Know Guides are a suite of documents that provide useful information about

More information

Department of Health and Human Services OFFICE OF INSPECTOR GENERAL

Department of Health and Human Services OFFICE OF INSPECTOR GENERAL Department of Health and Human Services OFFICE OF INSPECTOR GENERAL NEW YORK S CLAIMS FOR MEDICAID SERVICES PROVIDED UNDER ITS TRAUMATIC BRAIN INJURY WAIVER PROGRAM DID NOT COMPLY WITH CERTAIN FEDERAL

More information

Synchronizing Medicare policy across payment models

Synchronizing Medicare policy across payment models Synchronizing Medicare policy across payment models C h a p t e r1 C H A P T E R 1 Synchronizing Medicare policy across payment models Chapter summary In this chapter Historically, Medicare has had two

More information

HCCs and Star-Ratings: An IPA s Successful Approach to Revenue Integrity. Nancy Hirschl, CCS Victoria McKemy, MHA James Taylor, MD, CPC

HCCs and Star-Ratings: An IPA s Successful Approach to Revenue Integrity. Nancy Hirschl, CCS Victoria McKemy, MHA James Taylor, MD, CPC HCCs and Star-Ratings: An IPA s Successful Approach to Revenue Integrity Nancy Hirschl, CCS Victoria McKemy, MHA James Taylor, MD, CPC 1 Introduction Agenda HCCs (Hierarchical Condition Categories) Diagnosis

More information

Simple linear regression

Simple linear regression Simple linear regression Introduction Simple linear regression is a statistical method for obtaining a formula to predict values of one variable from another where there is a causal relationship between

More information

Medicare Risk-Adjustment & Correct Coding 101. Rev. 10_31_14. Provider Training

Medicare Risk-Adjustment & Correct Coding 101. Rev. 10_31_14. Provider Training Medicare Risk-Adjustment & Correct Coding 101 Rev. 10_31_14 Provider Training Objectives Medicare Advantage - Overview Risk Adjustment 101 Coding and Medical Record Documentation Requirements Medicare

More information

The Critical Importance of Targeting (or It s the targeting, stupid. )

The Critical Importance of Targeting (or It s the targeting, stupid. ) The Critical Importance of Targeting (or It s the targeting, stupid. ) Randall Brown NHPF Targeting High-Cost Medicare Beneficiaries to Improve Care and Reduce Spending: Finding the Bull's-Eye March 9,

More information

Advanced Statistical Analysis of Mortality. Rhodes, Thomas E. and Freitas, Stephen A. MIB, Inc. 160 University Avenue. Westwood, MA 02090

Advanced Statistical Analysis of Mortality. Rhodes, Thomas E. and Freitas, Stephen A. MIB, Inc. 160 University Avenue. Westwood, MA 02090 Advanced Statistical Analysis of Mortality Rhodes, Thomas E. and Freitas, Stephen A. MIB, Inc 160 University Avenue Westwood, MA 02090 001-(781)-751-6356 fax 001-(781)-329-3379 trhodes@mib.com Abstract

More information

Papers presented at the ICES-III, June 18-21, 2007, Montreal, Quebec, Canada

Papers presented at the ICES-III, June 18-21, 2007, Montreal, Quebec, Canada A Comparison of the Results from the Old and New Private Sector Sample Designs for the Medical Expenditure Panel Survey-Insurance Component John P. Sommers 1 Anne T. Kearney 2 1 Agency for Healthcare Research

More information

Presented by Bradford & Barthel, LLP Sherri M. Dozier, Director of Client Development and Relations Large Loss Department Specialist

Presented by Bradford & Barthel, LLP Sherri M. Dozier, Director of Client Development and Relations Large Loss Department Specialist Presented by Bradford & Barthel, LLP Sherri M. Dozier, Director of Client Development and Relations Large Loss Department Specialist Approximately 12.4% of Gross Wages (F.I.C.A) pay for Social Security.

More information

Descriptive Statistics

Descriptive Statistics Descriptive Statistics Primer Descriptive statistics Central tendency Variation Relative position Relationships Calculating descriptive statistics Descriptive Statistics Purpose to describe or summarize

More information

E m p l o y e e F i n a n c i a l W e l l n e s s

E m p l o y e e F i n a n c i a l W e l l n e s s 2015 Survey E m p l o y e e F i n a n c i a l W e l l n e s s S u r v e y R e s u l t s O v e r a l l 2 K n o w l e d g e & P r i o r i t i e s W o r k p l a c e 3-4 W e l l n e s s E m p l o y e e 5 A

More information

Supporting Statement Part B. Collections of Information Employing Statistical Methods

Supporting Statement Part B. Collections of Information Employing Statistical Methods Supporting Statement Part B Collections of Information Employing Statistical Methods Overview This field test will use a probability sample of each Program s eligible participants. Because the purpose

More information

ICD-10 DELAY: Relief or Grief?

ICD-10 DELAY: Relief or Grief? ICD-10 DELAY: Relief or Grief? PETER EDU MD, CPC, CPC-I, CCS Healthcare Sr. Training Manager TeleDevelopment Services, Inc. OUTLINE 1. Background 2. What s new with ICD-10? 3. Impact of ICD-10-CM implementation

More information

Gold Coast Health IT Resource Center. Accountable Care Organization (ACO)

Gold Coast Health IT Resource Center. Accountable Care Organization (ACO) Gold Coast Health IT Resource Center Accountable Care Organization (ACO) August 27, 2013 Copyright 2013 Gold Coast HIT 1 Agenda Upcoming Webinars ACO s Copyright 2013 Gold Coast HIT 2 Upcoming Webinars

More information

HDE FREE WEBINAR SERIES: BIDDING, RISK ADJUSTMENT, AND STARS. May 3, 2012

HDE FREE WEBINAR SERIES: BIDDING, RISK ADJUSTMENT, AND STARS. May 3, 2012 HDE FREE WEBINAR SERIES: BIDDING, RISK ADJUSTMENT, AND STARS May 3, 2012 AGENDA Impact of Star Ratings on 2013 Part C bid Looking ahead: 2014 & beyond How risk scores & QBPs work hand-in-hand to maximize

More information

CMS Next Generation ACO Model. Payment Models Work Group April 20 th, 2015

CMS Next Generation ACO Model. Payment Models Work Group April 20 th, 2015 CMS Next Generation ACO Model Payment Models Work Group April 20 th, 2015 1 Why is there a new ACO model? To address concerns about certain design elements of the existing Pioneer Program and the MSSP

More information

STATES COLLECTION OF REBATES FOR DRUGS PAID THROUGH MEDICAID MANAGED CARE ORGANIZATIONS

STATES COLLECTION OF REBATES FOR DRUGS PAID THROUGH MEDICAID MANAGED CARE ORGANIZATIONS Department of Health and Human Services OFFICE OF INSPECTOR GENERAL STATES COLLECTION OF REBATES FOR DRUGS PAID THROUGH MEDICAID MANAGED CARE ORGANIZATIONS Daniel R. Levinson Inspector General September

More information

HCC/RxHCC Risk Tutorial for SETMA

HCC/RxHCC Risk Tutorial for SETMA HCC/RxHCC Risk Tutorial for SETMA Table of Contents What Provider Documentation is necessary in order to qualify a diagnosis as an HCC 2 or RxHCC for payment? What steps must be taken take to qualify a

More information

May 22, 2012. Report Number: A-09-11-02047

May 22, 2012. Report Number: A-09-11-02047 May 22, 2012 OFFICE OF AUDIT SERVICES, REGION IX 90-7 TH STREET, SUITE 3-650 SAN FRANCISCO, CA 94103 Report Number: A-09-11-02047 Ms. Patricia McManaman Director Department of Human Services State of Hawaii

More information

Risk Adjustment Data Validation Study Frequently Asked Questions

Risk Adjustment Data Validation Study Frequently Asked Questions Risk Adjustment Data Validation Study Frequently Asked Questions MEDICAL RECORD SUBMISSION Q1: Can medical groups gather all the medical records for the data validation and send them all at once? A1: Please

More information

2014-2015 Holistic Rating Training Requirements. Texas Education Agency Student Assessment Division

2014-2015 Holistic Rating Training Requirements. Texas Education Agency Student Assessment Division 2014-2015 Holistic Rating Training Requirements Texas Education Agency Student Assessment Division Disclaimer These slides have been prepared by the Student Assessment Division of the Texas Education Agency.

More information

Frequent Outpatient Emergency Department Use by New Hampshire Medicaid Members

Frequent Outpatient Emergency Department Use by New Hampshire Medicaid Members Frequent Outpatient Emergency Department Use by New Hampshire Medicaid Members An Evaluation of Prevalence, Diagnoses, Utilization, and Payments A report prepared for the New Hampshire Department of Health

More information

AP STATISTICS 2010 SCORING GUIDELINES

AP STATISTICS 2010 SCORING GUIDELINES 2010 SCORING GUIDELINES Question 4 Intent of Question The primary goals of this question were to (1) assess students ability to calculate an expected value and a standard deviation; (2) recognize the applicability

More information

Revolution or Evolution: What s Happening Next for MedAdv and Prescription Drug Plans

Revolution or Evolution: What s Happening Next for MedAdv and Prescription Drug Plans Revolution or Evolution: What s Happening Next for MedAdv and Prescription Drug Plans Issues & Trends in Medicare Supplement Insurance 2012 Conference Presented by: T. Scott Bentley, FSA, MAAA Consulting

More information

Place in College Curriculum: This course is required for the Medical Coding Certificate.

Place in College Curriculum: This course is required for the Medical Coding Certificate. Section I Course Title: CPT Coding II Course Code: HSC102 Lecture Hours: 3 Lab Hours: 0 Credits: 3 Course Description: This is a continuation of CPT Coding I. This course will focus not only on the aspects

More information

ICD-10-CM/PCS Transition Fact Sheet

ICD-10-CM/PCS Transition Fact Sheet ICD-10-CM/PCS Transition Fact Sheet Reed Group 10155 Westmoor Drive, Suite 210 Westminster, CO 80021 Notice: 2014 Reed Group, Ltd. All rights reserved. This document is made available for informational

More information

Audit Sampling 101. BY: Christopher L. Mitchell, MBA, CIA, CISA, CCSA Cmitchell@KBAGroupLLP.com

Audit Sampling 101. BY: Christopher L. Mitchell, MBA, CIA, CISA, CCSA Cmitchell@KBAGroupLLP.com Audit Sampling 101 BY: Christopher L. Mitchell, MBA, CIA, CISA, CCSA Cmitchell@KBAGroupLLP.com BIO Principal KBA s Risk Advisory Services Team 15 years of internal controls experience within the following

More information

National Medicare Readmission. Centers for Medicare and Medicare Services

National Medicare Readmission. Centers for Medicare and Medicare Services National Medicare Readmission Findings: Recent Data and Trends Office of Information Products and Data Analytics Office of Information Products and Data Analytics Centers for Medicare and Medicare Services

More information

The Value Quadrant of Healthcare Reform. 2008 Pharos Innovations, LLC. All Rights Reserved.

The Value Quadrant of Healthcare Reform. 2008 Pharos Innovations, LLC. All Rights Reserved. The Value Quadrant of Healthcare Reform ACOs in PPACA Provider Organizations or networked groups Accountable for quality, cost and overall care of defined population of Medicare FFS benes Key metrics to

More information

EQR PROTOCOL 4 VALIDATION OF ENCOUNTER DATA REPORTED BY THE MCO

EQR PROTOCOL 4 VALIDATION OF ENCOUNTER DATA REPORTED BY THE MCO OMB Approval No. 0938-0786 EQR PROTOCOL 4 VALIDATION OF ENCOUNTER DATA REPORTED BY THE MCO A Voluntary Protocol for External Quality Review (EQR) Protocol 1: Assessment of Compliance with Medicaid Managed

More information

CALCULATIONS & STATISTICS

CALCULATIONS & STATISTICS CALCULATIONS & STATISTICS CALCULATION OF SCORES Conversion of 1-5 scale to 0-100 scores When you look at your report, you will notice that the scores are reported on a 0-100 scale, even though respondents

More information

EARLY INDICATIONS OF CHANGES TO 2014 MAO PAYMENT METHODOLOGY

EARLY INDICATIONS OF CHANGES TO 2014 MAO PAYMENT METHODOLOGY Early indications of changes to the 2015 medicare advantage payment methodology and the potential effect on medicare advantage organizations and beneficiaries February 6, 2014 GLENN GIESE FSA, MAAA KELLY

More information

They re Not For the Faint of Heart Christine Rinn Chandra Westergaard

They re Not For the Faint of Heart Christine Rinn Chandra Westergaard Medicare Advantage and Part D They re Not For the Faint of Heart Christine Rinn Chandra Westergaard Introduction Changes to the Medicare Advantage and Part D programs may make participation less attractive

More information

Importance of Auditing

Importance of Auditing Medicare 201: Practitioner Importance of Auditing EY Fraud Investigation and Dispute Services Jennifer Shimek, Senior Manager Gretchen Segado, Manager Agenda Importance of Auditing National and Local Coding

More information

BENEFICIARIES REMAIN VULNERABLE TO SALES AGENTS MARKETING OF MEDICARE ADVANTAGE PLANS

BENEFICIARIES REMAIN VULNERABLE TO SALES AGENTS MARKETING OF MEDICARE ADVANTAGE PLANS Department of Health and Human Services OFFICE OF INSPECTOR GENERAL BENEFICIARIES REMAIN VULNERABLE TO SALES AGENTS MARKETING OF MEDICARE ADVANTAGE PLANS Daniel R. Levinson Inspector General March 2010

More information

Assessing the Impact of a Tablet-PC-based Classroom Interaction System

Assessing the Impact of a Tablet-PC-based Classroom Interaction System STo appear in Proceedings of Workshop on the Impact of Pen-Based Technology on Education (WIPTE) 2008. Assessing the Impact of a Tablet-PC-based Classroom Interaction System Kimberle Koile David Singer

More information

Greg Peterson, MPA, PhD candidate Melissa McCarthy, PhD Presentation for 2013 AcademyHealth Annual Research Meeting

Greg Peterson, MPA, PhD candidate Melissa McCarthy, PhD Presentation for 2013 AcademyHealth Annual Research Meeting Greg Peterson, MPA, PhD candidate Melissa McCarthy, PhD Presentation for 2013 AcademyHealth Annual Research Meeting Medicare Coordinated Care Demonstration (MCCD) Established in Balanced Budget Act of

More information

Full-Cost Accounting and Certification Modalities in FP7

Full-Cost Accounting and Certification Modalities in FP7 Prague, 30 March 2009 Full-Cost Accounting and Certification Modalities in FP7 Philippe Coenjaarts European Commission DG Research Overview of presentation Accountability context FP7 Accounting modalities

More information

Participating Accountable Care Organizations (ACOs) that meet quality performance standards will be eligible to receive payments for shared savings.

Participating Accountable Care Organizations (ACOs) that meet quality performance standards will be eligible to receive payments for shared savings. Background Sec. 3022 of the Patient Protection and Affordable Care Act (PPACA) requires the Secretary to establish the Medicare Shared Savings Program by Jan. 1, 2012 Program goals: Promote accountability

More information

Office Managers Association at Presbyterian Hospital of Plano

Office Managers Association at Presbyterian Hospital of Plano Office Managers Association at Presbyterian Hospital of Plano Update your charge slips annually Team approach Pain management example Grace period discontinued! New CPT, HCPCS and ICD-9 codes Changed definitions

More information

OFFICE OF INSPECTOR GENERAL

OFFICE OF INSPECTOR GENERAL Department of Health and Human Services OFFICE OF INSPECTOR GENERAL Physical And Occupational Therapy in Nursing Homes Cost of Improper Billings to Medicare JUNE GIBBS BROWN Inspector General AUGUST 1999

More information

Medicare Part D Frequently Asked Questions: Eligibility & Enrollment

Medicare Part D Frequently Asked Questions: Eligibility & Enrollment Medicare Part D Frequently Asked Questions: Eligibility & Enrollment This list of Frequently Asked Questions regarding eligibility and enrollment issues in the new Medicare Part D prescription drug benefit

More information

Health Meeting June 10-12, 2013 Baltimore, MD. Session 7 PD, Changes Coming to Medicare Supplement and Medicare Advantage

Health Meeting June 10-12, 2013 Baltimore, MD. Session 7 PD, Changes Coming to Medicare Supplement and Medicare Advantage Health Meeting June 10-12, 2013 Baltimore, MD Session 7 PD, Changes Coming to Medicare Supplement and Medicare Advantage Moderator: Ivy Dong, FSA, MAAA Presenters: T Scott Bentley FSA,MAAA Mark J Cary

More information

ICD-10 in the Provider Newsletter

ICD-10 in the Provider Newsletter ICD-10 in the Provider Newsletter ICD-10 CM Code Structure, July 2013 ICD-10 Implementation, April 2013 ICD-10 Manual, January 2013 ICD-10 Back on Track, October 2012 ICD-10 Training, July 2012 ICD-10

More information

Medicare Part C & D Star Ratings: Update for 2016. August 5, 2015 Part C & D User Group Call

Medicare Part C & D Star Ratings: Update for 2016. August 5, 2015 Part C & D User Group Call Medicare Part C & D Star Ratings: Update for 2016 August 5, 2015 Part C & D User Group Call Session Overview 2016 Star Ratings Changes announced in Call Letter. HPMS Plan Previews. 2016 Display Measures.

More information

Medicare accountable care organization (ACO) update

Medicare accountable care organization (ACO) update Medicare accountable care organization (ACO) update April 4, 2013 David Glass and Jeff Stensland Today s presentation Background Description of ACO models in Medicare Strengths and weaknesses of ACOs vs.

More information

Section 3: Employment-Based Health Insurance

Section 3: Employment-Based Health Insurance Section 3: Employment-Based Health Insurance Availability of coverage Employer offer rates Eligibility Access, take-up, and coverage Cost of coverage & cost sharing Total premium Employer/employee shares

More information

Medicare Supplement Standardized Plans

Medicare Supplement Standardized Plans Medicare Supplement Standardized Plans There are many kinds of Medicare Supplement Plan Different plans are designated with a letter Available plans include A, B, C, D, F, G, K, L, M, & N Not all plans

More information

2014: Volume 4, Number 1. A publication of the Centers for Medicare & Medicaid Services, Office of Information Products & Data Analytics

2014: Volume 4, Number 1. A publication of the Centers for Medicare & Medicaid Services, Office of Information Products & Data Analytics 2014: Volume 4, Number 1 A publication of the Centers for Medicare & Medicaid Services, Office of Information Products & Data Analytics Medicare Post-Acute Care Episodes and Payment Bundling Melissa Morley,¹

More information

National Policy Library Document

National Policy Library Document National Policy Library Document Policy Name: Medicare Sales Materials Policy No.: TR920-122549 This Policy is applicable to the following: Department(s): Marketing and Communication Business Unit(s):

More information

Private Fee-For-Service -----Provider Questions and Answers

Private Fee-For-Service -----Provider Questions and Answers Private Fee-For-Service -----Provider Questions and Answers 1. What qualifications must a health care provider have in order to be eligible to furnish services to Medicare beneficiaries who are enrolled

More information

Risk Adjustment: Key Standards, Developments, and Risks in Medicare Advantage and Beyond

Risk Adjustment: Key Standards, Developments, and Risks in Medicare Advantage and Beyond Risk Adjustment: Key Standards, Developments, and Risks in Medicare Advantage and Beyond This roundtable discussion is brought to you by the Medicare Advantage (MA) and Part D Affinity Group of the Payors,

More information

1. What is the critical value for this 95% confidence interval? CV = z.025 = invnorm(0.025) = 1.96

1. What is the critical value for this 95% confidence interval? CV = z.025 = invnorm(0.025) = 1.96 1 Final Review 2 Review 2.1 CI 1-propZint Scenario 1 A TV manufacturer claims in its warranty brochure that in the past not more than 10 percent of its TV sets needed any repair during the first two years

More information

THE KRUSKAL WALLLIS TEST

THE KRUSKAL WALLLIS TEST THE KRUSKAL WALLLIS TEST TEODORA H. MEHOTCHEVA Wednesday, 23 rd April 08 THE KRUSKAL-WALLIS TEST: The non-parametric alternative to ANOVA: testing for difference between several independent groups 2 NON

More information

A Basic Guide to Analyzing Individual Scores Data with SPSS

A Basic Guide to Analyzing Individual Scores Data with SPSS A Basic Guide to Analyzing Individual Scores Data with SPSS Step 1. Clean the data file Open the Excel file with your data. You may get the following message: If you get this message, click yes. Delete

More information

Independent t- Test (Comparing Two Means)

Independent t- Test (Comparing Two Means) Independent t- Test (Comparing Two Means) The objectives of this lesson are to learn: the definition/purpose of independent t-test when to use the independent t-test the use of SPSS to complete an independent

More information

ACO Type Initiatives

ACO Type Initiatives If you proposed an ACO initiative, please fill our this Comparison of Elements for Participation in Medicare Shared Savings Program (MSSP) to State SIM ACO Test Proposal From Funding Opportunity Announcement:

More information

Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare

Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare O N L I N E A P P E N D I X E S 6 Report on comparing quality among Medicare Advantage plans and between Medicare Advantage and fee-for-service Medicare 6-A O N L I N E A P P E N D I X Current quality

More information

School of Health Sciences HEALTH INFORMATION TECHNOLOGY

School of Health Sciences HEALTH INFORMATION TECHNOLOGY School of Health Sciences HEALTH INFORMATION TECHNOLOGY Course: HIT 1020 - Basic Diagnosis Coding Credit Hours: 3cr hours Instructor: TBA Office Phone: Division of Allied Health (801) 957-6200 Office Hours:

More information

Health Spring Meeting June 2009. Session # 27 TS: Medicare Advantage: Revenue Payments + Part D Accounting

Health Spring Meeting June 2009. Session # 27 TS: Medicare Advantage: Revenue Payments + Part D Accounting Health Spring Meeting June 2009 Session # 27 TS: Medicare Advantage: Revenue Payments + Part D Accounting Brian M. Collender, FSA, MAAA Judah Z. Rabinowitz, FSA, MAAA, FCA Moderator: Judah Z. Rabinowitz,

More information

Session 5 PD, Keys to Succeeding in the Medicare Advantage Market. Moderator/Presenter: Corey N. Berger, FSA, MAAA

Session 5 PD, Keys to Succeeding in the Medicare Advantage Market. Moderator/Presenter: Corey N. Berger, FSA, MAAA Session 5 PD, Keys to Succeeding in the Medicare Advantage Market Moderator/Presenter: Corey N. Berger, FSA, MAAA Presenters: Dylan Ascolese, FSA, MAAA JoAnn Bogolin, ASA, FCA, MAAA Stephen Lawrence Webb,

More information

Information Technology Services will be updating the mark sense test scoring hardware and software on Monday, May 18, 2015. We will continue to score

Information Technology Services will be updating the mark sense test scoring hardware and software on Monday, May 18, 2015. We will continue to score Information Technology Services will be updating the mark sense test scoring hardware and software on Monday, May 18, 2015. We will continue to score all Spring term exams utilizing the current hardware

More information

The term bid can be confusing because no competitive bidding takes place. If CMS accepts plan bids, it signs contracts with the MAOs.

The term bid can be confusing because no competitive bidding takes place. If CMS accepts plan bids, it signs contracts with the MAOs. United States Government Accountability Office Washington, DC 20548 February 4, 2011 Congressional Requesters Subject: Medicare Advantage: Comparison of Plan Bids to Fee-for-Service Spending by Plan and

More information

MEDICARE CONTRACTORS PAYMENTS TO PROVIDERS FOR HOSPITAL OUTPATIENT DENTAL SERVICES IN JURISDICTION K DID NOT COMPLY WITH MEDICARE REQUIREMENTS

MEDICARE CONTRACTORS PAYMENTS TO PROVIDERS FOR HOSPITAL OUTPATIENT DENTAL SERVICES IN JURISDICTION K DID NOT COMPLY WITH MEDICARE REQUIREMENTS Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE CONTRACTORS PAYMENTS TO PROVIDERS FOR HOSPITAL OUTPATIENT DENTAL SERVICES IN JURISDICTION K DID NOT COMPLY WITH MEDICARE REQUIREMENTS

More information

Dual Eligible and High Risk Populations: A Case for Integrated Care and Redesign

Dual Eligible and High Risk Populations: A Case for Integrated Care and Redesign Dual Eligible and High Risk Populations: A Case for Integrated Care and Redesign Peggy Johnson, MD Chief of Psychiatry, Commonwealth Care Alliance Twitter Handle CCABoston May 15, 2014 DISCLAIMER: The

More information

VA Office of Inspector General

VA Office of Inspector General VA Office of Inspector General OFFICE OF AUDITS AND EVALUATIONS Veterans Health Administration Audit of Non-VA Medical Care Claims for Emergency Transportation March 2, 2015 13-01530-137 ACRONYMS CBO CMS

More information

Key Points about Star Ratings from the CMS 2016 Final Call Letter

Key Points about Star Ratings from the CMS 2016 Final Call Letter News from April 2015 Key Points about Star Ratings from the CMS 2016 Final Call Letter On April 6, 2015 CMS released the Announcement of Methodological Changes for Calendar Year 2016 for Medicare Advantage

More information

2015 Data Validation Strategy

2015 Data Validation Strategy 2015 Data Validation Strategy This data validation strategy details how the American College of Emergency Physicians (ACEP), a medical specialty society representing more than 33,000 emergency physicians,

More information

Chart 11-1. Number of dialysis facilities is growing, and share of for-profit and freestanding dialysis providers is increasing

Chart 11-1. Number of dialysis facilities is growing, and share of for-profit and freestanding dialysis providers is increasing 11 0 Chart 11-1. Number of dialysis facilities is growing, and share of for-profit and freestanding dialysis providers is increasing Average annual percent change 2014 2009 2014 2013 2014 Total number

More information

Achieving Real Program Integrity 2011 NAMD Annual Conference

Achieving Real Program Integrity 2011 NAMD Annual Conference Achieving Real Program Integrity 2011 NAMD Annual Conference Center for Program Integrity Centers for Medicare & Medicaid Services Angela Brice-Smith Director, Medicaid Integrity Group November 9, 2011

More information

THE OREGON STATE REHABILITATION COUNCIL AND OFFICE OF VOCATIONAL REHABILITATION SERVICES 2008 CLIENT CONSUMER SATISFACTION SURVEY

THE OREGON STATE REHABILITATION COUNCIL AND OFFICE OF VOCATIONAL REHABILITATION SERVICES 2008 CLIENT CONSUMER SATISFACTION SURVEY THE OREGON STATE REHABILITATION COUNCIL AND OFFICE OF VOCATIONAL REHABILITATION SERVICES 2008 CLIENT CONSUMER SATISFACTION SURVEY Assisting Oregonians with Disabilities Achieve And Maintain Employment

More information

MASTER COURSE SYLLABUS-PROTOTYPE PSYCHOLOGY 2317 STATISTICAL METHODS FOR THE BEHAVIORAL SCIENCES

MASTER COURSE SYLLABUS-PROTOTYPE PSYCHOLOGY 2317 STATISTICAL METHODS FOR THE BEHAVIORAL SCIENCES MASTER COURSE SYLLABUS-PROTOTYPE THE PSYCHOLOGY DEPARTMENT VALUES ACADEMIC FREEDOM AND THUS OFFERS THIS MASTER SYLLABUS-PROTOTYPE ONLY AS A GUIDE. THE INSTRUCTORS ARE FREE TO ADAPT THEIR COURSE SYLLABI

More information

Audit authority Audits of Systems, Operations and Accounts

Audit authority Audits of Systems, Operations and Accounts Audit authority Audits of Systems, Operations and Accounts Trainer:Dermot Byrne Head of Authority ERDF Audit Authority, Ireland Brussels September 2014 This training has been organised by EIPA-Ecorys-PwC

More information

Mean = (sum of the values / the number of the value) if probabilities are equal

Mean = (sum of the values / the number of the value) if probabilities are equal Population Mean Mean = (sum of the values / the number of the value) if probabilities are equal Compute the population mean Population/Sample mean: 1. Collect the data 2. sum all the values in the population/sample.

More information

Special Needs Plan Provider Education

Special Needs Plan Provider Education Special Needs Plan Provider Education Reviewed September 2014 Learning Goals What is a Special Needs Plan (SNPs) What differentiates a SNP from other MA plans What SNPs are offered by Freedom Health and

More information

Regression Analysis: A Complete Example

Regression Analysis: A Complete Example Regression Analysis: A Complete Example This section works out an example that includes all the topics we have discussed so far in this chapter. A complete example of regression analysis. PhotoDisc, Inc./Getty

More information

FFor members population, both in and out of

FFor members population, both in and out of Risk adjustment: Questions everyone should be asking in 2014 Expert presenters Jay Baker, Director, Commercial Risk Adjustment, Optum Scott Howell, MD, Senior National Medical Director FFor members population,

More information

Def: The standard normal distribution is a normal probability distribution that has a mean of 0 and a standard deviation of 1.

Def: The standard normal distribution is a normal probability distribution that has a mean of 0 and a standard deviation of 1. Lecture 6: Chapter 6: Normal Probability Distributions A normal distribution is a continuous probability distribution for a random variable x. The graph of a normal distribution is called the normal curve.

More information

Total Cost of Cancer Care by Site of Service: Physician Office vs Outpatient Hospital

Total Cost of Cancer Care by Site of Service: Physician Office vs Outpatient Hospital Total Cost of Cancer Care by Site of Service: Physician Office vs Outpatient Hospital Prepared by Avalere Health, LLC Page 2 Executive Summary Avalere Health analyzed three years of commercial health plan

More information

How the Marketplaces Prevailed (Despite Politics)

How the Marketplaces Prevailed (Despite Politics) How the Marketplaces Prevailed (Despite Politics) Bill Fox, JD, MA Vice President, Healthcare & Life Sciences MarkLogic Corporation Source SLIDE: 2 Reducing the Number of Uninsured Source Source SLIDE:

More information

Medicare Managed Care Manual Chapter 5 - Quality Assessment

Medicare Managed Care Manual Chapter 5 - Quality Assessment Medicare Managed Care Manual Chapter 5 - Quality Assessment Transmittals Issued for this Chapter Table of Contents (Rev. 117, 08-08-14) 10 Introduction 20 Medicare Quality Improvement Program 20.1 Chronic

More information

Statistical & Technical Team

Statistical & Technical Team Statistical & Technical Team A Practical Guide to Sampling This guide is brought to you by the Statistical and Technical Team, who form part of the VFM Development Team. They are responsible for advice

More information

APPENDIX N. Data Validation Using Data Descriptors

APPENDIX N. Data Validation Using Data Descriptors APPENDIX N Data Validation Using Data Descriptors Data validation is often defined by six data descriptors: 1) reports to decision maker 2) documentation 3) data sources 4) analytical method and detection

More information

2015 TN Accountability Protocol

2015 TN Accountability Protocol SAS EVAAS 2015 TN Accountability Protocol 06/09/2015 2015 TN Accountability Protocol Contents 1 Document Intent...4 2 Accountability Background...4 2.1 Accountability Subjects... 4 2.2 Accountability Subgroups...

More information

2016 Medicaid Managed Care Rate Development Guide

2016 Medicaid Managed Care Rate Development Guide DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore, Maryland 21244-1850 Disabled and Elderly Health Programs Group Introduction

More information

Introduction to Risk Adjustment Programs for Medicare Advantage and the Affordable Care Act (Commercial Health Insurance Exchange)

Introduction to Risk Adjustment Programs for Medicare Advantage and the Affordable Care Act (Commercial Health Insurance Exchange) Introduction to Risk Adjustment Programs for Medicare Advantage and the Affordable Care Act (Commercial Health Insurance Exchange) November, 2014 An independent licensee of the Blue Cross and Blue Shield

More information