By Tom Peterson, SVP, Care Optimization and Risk Adjustment, SCIO Health Analytics
Twitter: @SCIOanalytics
Several months ago, the Centers for Medicare and Medicaid Services (CMS) released the Final 2018 Call Letter, which describes exactly what rules, regulations, and reimbursement Medicare Advantage (MA) Organizations will experience in the coming year.
The first challenge for health plans is to decipher exactly what these changes will mean – details of which are highlighted in the blog entitled Understanding: Step One in Dealing with the Shock of CMS Call Letter Changes and the webinar entitled Risk Adjustment Round-Up: Reviewing the CMS Call Letter and Other Trends. Understanding is just half the battle, though. Health plans then need to determine how to implement the required changes. That’s the hard part.
Here are five strategies that health plans can adopt to cope with the new requirements:
- Remember, it takes a team. Professionals from information technology, claims processing, finance, risk adjustment and other areas within the organization need to come together to assess the organization’s current state – as well as what needs to be accomplished to comply with the changes outlined in the CMS call letter. For example, this cross functional team needs to go beyond simply acknowledging the need to shift from a Risk Adjustment Payment System (RAPS) to an Electronic Data Processing System (EDPS) and actually define a specific process for the transition, with goals identified for specific points.
- Get on the same page. Typically, the priorities in the claims department revolve around paying claims in a timely manner while the IT department is concerned with getting things done efficiently. The cross functional team needs to overcome this divide and create alignment over what is really important – and establish a set of common priorities.
- Gain provider trust. When health plans ask providers to perform certain services for members in the pursuit of higher quality, it’s absolutely essential to get the “ask” right. For example, if the health plan indicates that certain members need to come in for mammograms and the providers have already performed mammograms for these members, trust will quickly erode. As such, it becomes difficult for health plans to prompt providers to perform certain services in the name of higher quality.
- Collaborate with providers. When providers do trust their providers, however, payers can move forward and work with them to improve quality. For example, payers can assess how many doctors’ visits should occur based on the volume of membership – and can work with providers to investigate why office visits have fallen off during certain time period and uncover potential documentation, reporting or care delivery shortcomings.
- Create learning opportunities. It’s important for payers to educate providers on proper documentation via real-life examples. For example, when documentation falls short, it’s important for payers to go beyond simply telling providers that their physicians are not documenting properly. Instead, they need to say something along the line of “We see that Dr. Smith is not documenting properly with a member who has diabetes with neurological manifestations. He needs to write the words ‘diabetes’ and ‘neurological manifestations’ together so that they are connected.”
These are just some of the ways that payers can meet the challenges inherent in the changes required by the CMS call letter. Can you think of any other actions that payers should consider?
This article was originally published on SCIO Health Analytics and is republished here with permission.