The new rule published on May 19, 2014, revises the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations to implement statutory requirements, improve program efficiencies, clarify program requirements, and improve payment accuracy for Contract Year (CY) 2015 in general. The provisions in the rule are effective immediately.
The final rule is accessible here.
Health Data Vision has analyzed these new rules and how they affect Risk Adjustment processes for Medicare Advantage plans. This blog summarizes and comments on the most significant points of these rules.
Problem: Tightened timeframes
Improving payment accuracy: The final regulation would implement the Affordable Care Act requirement that MA plans and Part D sponsors report and return identified Medicare overpayments. After the final risk adjustment deadline for a payment year, MA organizations will be allowed to submit data to correct overpayments but cannot submit diagnosis codes for additional payment. The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must report and return overpayments.
This requirement effectively tightens the timeframe in which Plans will be incentivized to verify the diagnosis that have been submitted through claims. Once outside that window, plans will be required to return over-payments without the ability to submit corrected diagnosis codes. Thus leaving only a downside for the health plans. For this reason Verify or Delete will become a much more sought after mechanism during chart reviews, particularly ahead of January sweeps.
HDVI’s addresses these tightened timeframes with the Verify, Delete plus Add functionality in our Workflow Platform.
Problem: More RADV’s More Often
Improved MA risk-adjustment data validation (RADV) audit appeals procedures: The rule strengthens RADV by streamlining the RADV audit appeals process by combining error rate calculation appeals and medical record review-determination appeals into one combined process. The streamlined process will reduce administrative burden on both MA plans and CMS.
CMS is making efforts to streamline the entire RADV process. The working assumption is that it will create a system where more plans can be audited on a regular basis. If this assumption is correct HDVI will see more demand for RADV assistance.
HDVI already has a strong automation service for RADV that reduces the effort and time required for RADV responses, while eliminating the majority of uncertainty and negative financial impact. Learn more about HDVI's Mock RADV.
Problem: Critical Reporting Measures
Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.
CMS has now incorporated the requirement to improve health for Medicare Advantage members. This means that reporting results of chart audits will become critical information to filter back to the plan for improvement initiatives. The reporting results will need to be audit specific, DOS specific and provider specific, which will require much more work than before. Computer assisted coding, error resolution and extremely efficient record retrieval are necessary in order for health plan’s to facilitate the increased volume before the reconciliation deadline.
With HDVI's Real-time Analytics and Secure Virtual Print Technology, increased volumes of health plan reporting are handled with ease, while (SVP) reduces provider abrasion.
Problem: Identifying Revoked Providers
Permit revocation of Medicare enrollment for abusive prescribing practices and patterns: CMS is adding the authority to revoke a physician’s or eligible professional’s Medicare enrollment if:
CMS determines that he or she has a pattern or practice of prescribing Part D drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or the pattern or practice of prescribing otherwise fails to meet Medicare requirements; or
His or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked; or
The applicable licensing or administrative body for any state in which a physician or eligible professional practices has suspended or revoked the physician or eligible professional’s ability to prescribe drugs.
Providing CMS the authority to revoke such prescribers’ Medicare enrollment will help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse.
It is not clear how CMS intends to track or communicate these revoked physicians, likely through the NPI/Taxonomy database. NPI is now a required submission element, so it is possible that CMS will simply reject certain NPI’s. This should be monitored closely in order to learn more and how to avoid submitting diagnoses from providers that are no longer permissible to treat Medicare Members.
A National Provider Database is frequently updated and available in HDVI’s Workflow Platform.
By Kristen Joyce, HDVI - Senior Director, Risk Adjustment