PROPOSED RULE - Issued January 10, 2014
What is it?
According to CMS the proposed rule would revise the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement statutory requirements; strengthen beneficiary protections; exclude plans that perform poorly; improve program efficiencies and clarify program requirements. The proposed rule also includes several provisions designed to improve payment accuracy.
To achieve all of this, CMS is proposing several changes which necessitate timelier monitoring of beneficiaries chronic conditions. The proposed rule would require health plans to remove erroneous diagnostic data from the Risk Adjustment database, with strong incentives to accomplish this prior to reconciliation (no more “deliberate ignorance”). The proposal also includes requirements for plans to make reportable efforts to improve beneficiary’s health outcomes (no more “reckless disregard”). CMS is further proposing that these new requirements be tied to STARS, thereby rewarding Health Plans that pursue improved health outcomes for Medicare Advantage members.
CMS is also proposing a 6-year look-back window, in conjunction with the new mechanism for over-payment reporting, on any errors found after the reconciliation submission (“constant diligence”). This process (already established) requires a plan to detail the operational flaws that allowed the error to occur, the number of beneficiaries it affects, the estimated total over-payment and what corrective actions the plan will take to prevent it from recurring.
What does it mean for health plans?
It would seem that CMS expects Health Plans to review all Medical Records, identify and remove all errors, and most importantly identify and close all gaps in care prior to reconciliation. If resources and physician tolerances were limitless this would be achievable, but we all know neither is.
So this means that Health Plans will need to revise chart audit targets. Gone are the days of suspecting to capture dropped or missed HCC diagnoses in an effort to maximize revenue. Instead, plans are expected to focus audits on potential errors and potential gaps in care.
However, plans shouldn’t expect that medical record documentation and encounter data will improve simply because CMS has strengthened the program reliance on it. Therefore, there will still be the same need to audit charts to obtain comprehensive diagnostic profiles where encounter data implies a documentation gap. The change here is that when plans identify assessment or documentation deficiencies in this process, CMS is expecting efforts in operational improvements to insure that the member’s care is not deficient and that errors are removed.
The “timely” requirement is the larger challenge. Plans are expected to: analyze lagged encounter data; target errors, deficiencies and gaps; review targeted charts, and react to the results optimally in the same data collection period.
The silver lining here is that identifying gaps in care should inspire follow-up, managed and coordinated care. This effort should not only close any gaps in care, but will also trigger appropriate revenue for any HCC conditions assessed and treated, as well as improve STARS ratings.
What should plans be doing to get ready?
There is no time to be wasted. CMS alerted MAOs this time last year that in 2014 there would be requirements for clinic follow-ups on Home Assessments to insure that all reported HCC conditions were being treated. The message there is that CMS is not paying plans for diagnoses, but rather for managing chronic conditions. This requirement is in place now, and there is no basis to believe that the proposed chart audit requirements will not be in place this time next year.
Health Plans should be making plans now for this expectation. If we assume that CMS will require reporting on health outcomes next year, plans will need to be ready.
Health plans should be making every effort to identify potential encounter data errors for 2011 through 2014 dates of service. Any diagnosis not supported by assessment notes should be deleted. Any gaps in care or documentation deficiencies identified for 2013 or 2014 should be referred for Care Management activities.
Health plans should begin now developing new targeting strategies to maximize health outcome results and documentation. Rather than targeting members, plans should begin targeting clinical areas for enhancements. The average plan will find Diabetes, Heart Conditions and Lung Conditions to be those with the highest drop-off rates. This is largely due to the ability to manage these conditions pharmaceutically. These conditions may appear to be un-treated from reviewing the documentation, when in fact they are not.
Currently at HDVI we are working with our Risk clients to review all reported HCCs and to identify cases where clinical assessments are necessary to manage the care continuum and document chronic conditions appropriately. Additionally, our MRCS Platform has modules specifically designed to improve a health plans ability to assess the quality of documentation supporting a diagnosis and to take decisive action to ensure submissions will pass muster with CMS.
This will help to identify the unique cluster of conditions that each of our clients will need to develop enhanced Care Management activities to insure the care continuum is not broken in the future, as well as highlight documentation deficiencies to support physician education activities.