Day 2 PPT 1 2019 OPCDI Symp Medicare Advantage Bresette Final 1... · Title: Microsoft PowerPoint -...
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1 This is the Full Title of a Session Medicare Advantage ‐‐ Impact from Diagnosis Codes Christopher Bresette, CPA Assistant Regional Inspector General for Audit Services 2 Medicare Program Traditional Medicare • CMS makes payments directly to providers, physicians, suppliers • Fee‐for‐service basis Medicare Advantage • CMS makes payments to MA organizations • MA organization pays providers, physicians, suppliers 2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
Transcript of Day 2 PPT 1 2019 OPCDI Symp Medicare Advantage Bresette Final 1... · Title: Microsoft PowerPoint -...
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This is the Full Title of a Session
Medicare Advantage ‐‐ Impact from Diagnosis Codes
Christopher Bresette, CPAAssistant Regional Inspector General for Audit Services
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Medicare Program
Traditional Medicare
• CMS makes payments directly to providers, physicians, suppliers
• Fee‐for‐service basis
Medicare Advantage
• CMS makes payments to MA organizations
• MA organization pays providers, physicians, suppliers
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Medicare Program
• Beneficiaries must choose between Traditional Medicare and Medicare Advantage
• Medicare Advantage provides beneficiaries a wider range of choices to obtain Medicare benefits
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Medicare Advantage Enrollment
2008 – 22%
2018 – 34%
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Medicare AdvantageEnrollment
2018
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$98
$146
$233
2008 2013 2018
Payments to MA Organizations (billions)
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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CapitatedPayments to MA
Organizations
• Goal: Approximate cost of providing care to enrollees
• Risk‐Adjusted Payments
– Demographic Status
– Health Status
– Separate Calculation for Each Beneficiary
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Payment Formula ‐ oversimplified
• Revenue requirements
• Health costs
• Administrative costs
• Profit
Specific MA Organization Base Rate
Specific MA Organization Base Rate
• Relative measure that reflects the additional or reduced costs that each enrollee is expected to incur compared to an average enrollee
Specific Beneficiary Risk Score
Specific Beneficiary Risk Score
• Base Rate x Risk Score
Payment
Amount
Formula
Payment
Amount
Formula
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Base Rate Calculation ‐Example
Revenue Required for Providing Medical Services – Standardized
• Medical Costs: $850
• Admin Costs: 100
• Profit: 50
Total $1,000
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Risk Scores‐‐
Calculated Annually for
Each Beneficiary
Demographic Status
• Gender / Age
• Institutionalized Status
• Medicaid Status
• Aged / Disabled
Health Status
• Diagnosis Codes
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Hierarchical Condition Categories
• Specific Beneficiary Diagnoses:– Hospital inpatient facilities,
– Hospital outpatient facilities, and
– Physician services
• 9,500 diagnosis codes map
to 79 HCCs
• At least one face‐to‐face encounter each year
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Risk Score‐‐ Example
Category Factor Value
78‐year Old Male 0.442
Non‐Medicaid
Not Institutionalized
HCCs (based on diagnoses)
Ischemic or Unspecified Stroke 0.317
Diabetes without Complication 0.118
Congestive Heart Failure 0.368
Risk Score 1.245
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Risk Score‐‐ Example
Monthly Payment Amount Calculation:
• Base Amount $1,000
• Risk Score 1.245
Payment Amount $1,245
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Risk Adjustment Factor‐‐ Example with Audit Finding
Category Factor Value
78‐year Old Male 0.442
Non‐Medicaid
Not Institutionalized
HCCs (based on diagnoses)
Ischemic or Unspecified Stroke 0.317
Diabetes Without Complication
0.118
Congestive Heart Failure 0.368
Risk Score 0.928
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Risk Adjustment Factor‐‐ Example with Audit Finding
Status Calculation
Original Monthly Payment $1,245
Revised Monthly Payment 928
Difference $ 317
Number of Months Enrolled
12
Overall Difference $3,804
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OIG Audits‐‐ What We Do
Data Mining
Access CMS Systems
Identify Areas to Review
Discussions with Medical
Professionals
Viability of Concerns
Identify Auditees
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Targeted Audits
To Date:
‐‐ 1 finalized – Essence Healthcare
‐‐ Many ongoing
More audits starting
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OIG Audits‐‐ Targeted Diagnosis Codes / HCCs
Review Areas – First Audit
• Acute Stroke ‐ 1 or 2 physician services without a corresponding diagnosis on an inpatient claim
• Major Depressive Disorder – 1 or 2 dates of services
Many lessons learned
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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OIG Audits‐‐ Targeted Diagnosis Codes / HCCs
Review Areas
• Revised Approaches
• New Audit Areas
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Thank you. Questions?
In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.
2019 Copyright, HCPro, a division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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