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Maximizing Your Quality Improvement Initiatives with Prospective Data Runs

Maximizing Your Quality Improvement Initiatives with Prospective Data Runs

What does the future hold for HEDIS® and your HEDIS results? No one can know for sure, but for quality improvement initiatives, prospective monthly runs can give you better insight and help you stay on top of results.

With monthly prospective data runs, health plans can monitor how each HEDIS measure and sub-measure is tracking towards a specific goal. Additionally, plans can conduct rolling 12-month reviews to track the status of year-to-date results (e.g., April 2019 to April 2020) to identify actual due dates of specific services to optimally focus outreach efforts.

Three Reasons Why High-Performing Plans Complete Prospective Runs

  1. Track trending towards goals, benchmarks, and/or last year’s submission results. NCQA’s new timeline for releasing HEDIS specifications allows plans to start improvement efforts and react sooner to new measures and measure changes.
  2. Create an off-season chart review project. During the project, medical record data can be collected for your HEDIS hybrid measures. In addition, we have a few administrative measure data collection forms that can be used to collect medical record data as well. This data is collected and then included with next season’s administrative data sources, reducing abstraction collection during the HEDIS season and maximizing administrative rates.
  3. Set targeted member and provider outreach efforts. With prospective monthly data runs, the most current gap lists can be sent to providers or used to coordinate with members to close gaps quickly to impact measurement year HEDIS rates.

To learn more about how prospective monthly data runs can benefit your quality improvement initiatives, email us or call 877.896.7350.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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HEDIS® 2020: What You Need to Know Now

HEDIS® 2020: What You Need to Know Now

Change can be stressful, especially when it comes to HEDIS®. With several updates anticipated in the coming months and years, you need to be prepared.

Advantmed’s HEDIS® experts have been monitoring the National Committee for Quality Assurance (NCQA) and the market overall. Based on our research, we have summarized several important changes anticipated for 2020 and beyond, including:

  • Allowable adjustments
  • IDSS 2020–2021 redesign
  • Timeline specification changes
  • Digital measures

Additionally, and perhaps more importantly, we’ve provided a few key questions you need to answer to confirm that you’re prepared for this HEDIS® season.

Review the changes and questions here.

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Download our webinar, Best Practices: Three Key Steps to Minimize RADV Exposure

Download our webinar, Best Practices: Three Key Steps to Minimize RADV Exposure

At Advantmed, we focus on helping health plans optimize risk and improve quality. Part of that preparation involves making sure you’re ready for a possible RADV audit.

Michelle Zilisch, Advantmed’s Director of Client Solutions, has been in the trenches with many health plans. In this seven-minute webinar, Michelle shares three key tactics you can employ to help minimize your RADV exposure.

During the webinar, you will learn:

  • Why having clean, complete data is so important – regardless of whether you’re audited or not
  • How thorough validation and review of your data will help you through a RADV
  • The important role a second-level coding review could play, and why it matters

This short webinar is seven-minutes long, but it could provide huge benefits should you go through a RADV audit.

Watch Best Practices: Three Key Steps to Minimize RADV Exposure today.

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Risk-Bearing Providers Gain Strategies for Optimizing Risk Adjustment, Quality and Care

Risk-Bearing Providers Gain Strategies for Optimizing Risk Adjustment, Quality and Care

Advantmed releases “Rise of Medicare Advantage Plans and its Implications for Risk-Bearing Healthcare Providers,” the second in a three-part series, “High Priorities for the U.S. Healthcare System: Powerful End-to-End Solution to Integrate Patient Care.”

Advantmed’s new white paper, “Rise of Medicare Advantage Plans and its Implications for Risk-Bearing Healthcare Providers,” examines trends driving the growing adoption of Medicare Advantage (MA) plans, provider opportunities and challenges in the increasingly value-based healthcare system, and offers innovative strategies for risk adjustment, quality and care management.

Learn about innovative approaches designed to meet growing demand for effective risk adjustment, quality and care strategies.

Effective Value-Based Strategies

Provider-led organizations are taking on risk but without gaining some of the benefits that MA plans have had, especially when it comes to risk-adjustment models.

Knowing how CMS uses Hierarchical Condition Categories (HCCs) to calculate expenditure benchmarks or PMPMs is critical for a risk-bearing provider’s ability to earn shared savings while avoiding shared loss.

Because MA plans have been able to optimize the HCC methodology with significant financial success, providers are well advised to study their methods.

Independent practice owners and health systems can gain highly relevant knowledge about operational viability and how to improve patient outcomes at reduced costs.

Practices that succeed at making the shift from fee-for-service to managing risk are routinely able to increase their practice profitability by at least 25 percent.

Innovative Solutions for Risk-Bearing Challenges

Advantmed’s powerful end-to-end solution integrates with patient care to help managed care organizations improve outcomes by delivering the optimal combination of capabilities designed to meet key objectives, including risk adjustment analytics, software containing NCQA-certified HEDIS® measures, medical record retrieval, medical record abstraction, in-home assessments, risk adjustment coding and provider education.

Want a more robust view of members and their care needs?

Advantmed’s Prospective Health Assessments (PHA) lays the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, enhancing disease management, and reducing utilization.

PHA also provides a full-spectrum, end-to-end approach to care to help providers identify gaps in care and manage patients more productively.

The greatest benefit goes to the patient, who will be guided toward more preventive care and self-management early in the care process.

To learn more click here.

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Medicare Advantage Plans Gain Insights into Effective Risk, Quality and Care Strategies

Medicare Advantage Plans Gain Insights into Effective Risk, Quality and Care Strategies

Advantmed releases “Federal Policy and Medicare’s Impact on the Economy,” the first in a three-part series, “High Priorities for the U.S. Healthcare System: Powerful End-to-End Solution to Integrate Patient Care.”

Advantmed’s new white paper, “Federal Policy and Medicare’s Impact on the Economy” was developed to support Medicare Advantage (MA) plans in their quest for innovative approaches to improve patient care.

Learn about opportunities for differentiation and financial success in a healthcare environment facing looming crises.

Staying Ahead of the Trends

Aging baby boomers are creating a significant shift across the U.S. healthcare system—from enrollment in private health insurance to Medicare.

In 2017 Medicare spending accounted for 15 percent of total federal spending and is projected to rise to 18 percent by 2028. 33 percent of Medicare beneficiaries were enrolled in Medicare Advantage plans, up from 19 percent in 2007.

If further cuts to Medicare entitlements occur in 2018, then deductibles and cost-sharing for seniors in original Medicare will likely increase.

This will make MA plans that much more attractive for baby boomers.

One important factor to keep in mind in terms of optimizing this opportunity: Risk-based contracting demonstrates superior clinical outcomes and improvement in mortality for patients—making value-based approaches critical.

MA plans should look at the full spectrum of the patient and adopt innovative quality and risk adjustment programs to meet the growing demand for effective care strategies.

End-to-End Solution

Advantmed’s powerful end-to-end solution integrates with patient care to help managed care organizations improve outcomes by delivering the optimal combination of capabilities designed to meet key objectives.

When implemented effectively and efficiently—and aligned with payment reform—it’s possible to enhance care coordination using analytics, in-home care, retrospective solutions and care management to significantly improve outcomes.

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Medicare Advantage Plans Get Ready for 2019

Medicare Advantage Plans Get Ready for 2019

Check out our Fact Sheet for the Medicare Advantage and Part D Rate Announcement and Call Letter

In response to CMS’s release of 2019 Medicare Advantage and Part D Rate Announcement and Call LetterAdvantmed has issued its Fact Sheet, highlighting key points to help Medicare Advantage (MA) plans understand the implications and prepare for these changes.

Now is the time for MA plans to shore up their capabilities related to reimbursement, medical cost management, and risk adjustment. This is no small task, so we are lending our expertise to MA plan leaders who can benefit from our experience.

Highlights

Here’s a look at some key points from the CMS Call Letter:

  • Finalizing the proposal to calculate risk scores by adding 25 percent of the risk score calculated using diagnoses from encounter data and FFS diagnoses with 75 percent of the risk score calculated with diagnoses from RAPS and FFS diagnoses.
  • Finalizing an updated HCC Risk Adjustment model that incorporates most of the proposed changes to the Part C risk adjustment model, such as adding mental health, substance use disorder, and chronic kidney disease conditions to the risk adjustment model, as well as a variety of additional technical updates.
  • +3.4 percent expected overall YOY change in revenue from Part C Methodology.
  • Expects the underlying coding trend to increase risk scores, on average, by 3.1 percent
  • Plans to begin implementing the “Payment Condition Count Model” to account for members with multiple conditions in 2020

It’s important for MA plans to put a process into place that enables them to gather and report encounter data, while quickly troubleshooting submission issues. Plans can rely on our specialized expertise because adjustments will impact plan performance, patient care, and compliance.

Our goal is to help plans integrate risk-adjustment strategies to meet growing regulatory and market demand for care quality that leads to better patient outcomes

To learn more contact info@advantmed.com or call 877.896.7350.

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Prospective Health Assessment Services Provide Actionable Insights into Member Health Status for Risk Adjustment and Quality

Prospective Health Assessment Services Provide Actionable Insights into Member Health Status for Risk Adjustment and Quality

By Nilay Shah, President of Provider Solutions

Why do health plans and provider groups need more information about their members’ health status?

Unfortunately, medical records and claims don’t always present a complete view of the patient’s health conditions and medical needs. To improve accuracy many health plans turn to companies like Advantmed to have a clinician visit a patient and conduct a comprehensive health assessment.

That’s one of the key value propositions of Advantmed’s comprehensive Prospective Health Assessments (PHAs)

In today’s complex healthcare environment, prospective health assessments are more vital than ever. They offer plans an opportunity to gain a robust view of patients and their care needs – a pathway to better manage patient’s health conditions more productively, and help providers deliver more effective care. Our PHAs also help lay the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, increasing STAR ratings, enhancing disease management, and reducing utilization through patient education and preventive care management.

To develop the most optimal health assessment program, health plans turn to us for advanced strategies to capture quality information, engage patients, improve health outcomes and reduce the cost of care.

Sophisticated Health Assessment Strategies

Advantmed now offers PHAs that are designed to empower health plans, provider groups and risk-bearing entities with actionable 360-degree insights into the health status of member populations. PHAs provide an effective tool for facilitating timely gap closure and improving care management initiatives. PHAs integrate the program needs of both risk adjustment and quality.

Advantmed’s PHAs focus on 1) identifying chronic conditions through an evidence-based medicine screening program, 2) re-capturing and documenting previous chronic conditions, and 3) closing quality care gaps. They provide real-time visibility into assessments and documentation, integrating analytics, physician-chart reviews, and evidence-based screenings to drive higher engagement rates and optimal results.

Members value the flexibility of having the assessment conducted by Advantmed’s highly-trained nurse practitioners in their home, in a centralized Advantmed clinic or in a primary care physician’s office.

Advantmed clients receive:

  • An average revenue increase from $620 to over $1,500 per assessment
  • The patient acceptance rate for in-home visits of greater than 35 percent
  • 100 percent electronic (tablet-based) assessments
  • 100 percent quality audits of all assessments

Advantmed integrates quality measures, including Star measures, HEDIS® and CAHPS®/HOS. The proprietary process involves a comprehensive assessment that focuses on member engagement and clinical profiles to gather the most accurate data.

The ELEVATE! platform allows clients to view project dashboards and drill-down options, including call metrics and detailed call comments, status on non-cooperating members and reason codes. All clinical data and HCCs are hyperlinked within the assessment.

This PHA offering further expands our exceptional portfolio of services and extends our commitment to enhancing financial, clinical and operational outcomes for MA plans and their members.

We welcome your input and feedback.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Critical Insights You Need for Risk-Adjusted Conditions…and Quality/Care Management Opportunities with Advantmed’s New Physician Record Reviews

Critical Insights You Need for Risk-Adjusted Conditions…and Quality/Care Management Opportunities with Advantmed’s New Physician Record Reviews

By Nilay Shah, President of Provider Solutions

Today, Medicare Advantage (MA) plans must gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms. The best way to do this is with a Physician Record Review (PRR), a two-stage retrospective medical record review process from a 1) certified coder and 2) board-certified physician.

The point of such a thorough review is to give physicians the ability to review progress notes for primary care, specialists’ hospital charts, radiology and laboratory results that are not routinely used in standard analytics and gain demonstrable actionable information.

What’s more, PRR identifies care opportunities in accordance with clinical guidelines. Advantmed’s physician staff members are board-certified in their areas of specialty and have the extensive risk-adjustment training to uncover the potential for risk-adjusting conditions left undetected by current programs.

Gaining a Complete Picture

PRRs represent one of the best opportunities to focus on Hierarchical Condition Categories (HCCs). Specifically, our team of physician reviewers identifies HCCs within each patient record, annotates risk adjustable conditions by page number, and integrates these outputs into a broader array of activities.

Advantmed’s PRRs also confirm the previous two years of submitted HCCs for clinical confirmation not currently submitted in the calendar year. The goal is to provide a complete picture for the risk-adjustment factor, increasing the accuracy of the patient’s risk score and, ideally, creating clean claims and faster reimbursements.

To learn more contact info@advantmed.com or call 877.896.7350.

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HEDIS® Season is the Reason: Make Year-round Preparation Part of Your Strategy

HEDIS® Season is the Reason: Make Year-round Preparation Part of Your Strategy

By Vandna Pandita, Vice President, Client Engagement & Product Operations

Fall, winter and then HEDIS®.  Yes, HEDIS.  It is its own season for many of us that work in healthcare.  However, the images of HEDIS season are quite different from other seasons. It is not defined by the temperature, the color of the leaves or the many holiday parties that we measure our days by.  It is the season of claims data, supplemental data sources, medical records, audit onsites and over-reads.  Lots and lots of over-reads.

The Healthcare Effectiveness Data and Information Set (HEDIS) was designed back in the early 1990’s by a coalition of employers, plans and the National Committee for Quality Assurance (NCQA®) to provide a consistent, measurable process for consumers of healthcare to assess health plan performance.  Since its inception, HEDIS has become one of the leading measurement sets of plan performance, used by direct consumers, as well as state and federal governments.

HEDIS is no longer considered to be a seasonal event.  Organizations commit resources year-round to manage data, assess activity, collect records and so on, all focused on higher reportable rates and improved member outcomes.  As you consider the upcoming HEDIS 2018 season, what are you most concerned about?  What are some of your greatest challenges?

If anxiety is kicking in, don’t let it.  It may seem late, but you still have the opportunity to ensure a successful reporting year.  We all know that HEDIS is built upon data.  If you haven’t already started processing your rates, you still have time to assess and scrub data.  Most importantly, spend some time confirming that you have full and comprehensive data to represent the measurement years relevant to your product line/reportable measures.

If you work with an IT or data team to extract the data set from an internal data warehouse, ensure you’ve confirmed that all required fields are included? Coordinate with your data team to do a spot check for the following data criteria:

  • If your system captures more than 10 diagnosis codes, are all codes included?
  • Are revenue codes included? Over the years, I have seen numerous data sets where the revenue codes were excluded upon extract, which created a significant negative impact on the reportability of measures such as Follow Up After Hospitalization for Mental Illness (FUH).
  • If you operate a Special Needs Plan, ensure that your data is appropriately aligned for reporting within its H contract, as well as Plan Benefit Package
  • Guarantee member enrollment spans should fall within your HEDIS reporting software’s criteria – many have limits on when an enrollment span can end so, be sure to check the file specifications.

Another, and in some ways most critical review of your data, is going to be scrubbing your provider data.  This provider data is key to minimize provider abrasion, maximize retrieval rates and will save your team a lot of time sorting it out later in the project when you won’t have the time or resources to do so effectively.  If you are working with a vendor to outreach and retrieve medical records for abstraction, having accurate provider data is critical as these resources are often less familiar with your provider network than your internal teams.  Next, prior to launching your chart chase project, review provider locations and addresses confirming as best as, and as clearly as possible, that you are sharing physical locations and that there are no PO Box addresses or addresses of billing companies rather than the provider’s physical address.

Finally, filter and review your provider type designations as well, keeping in mind that it’s better to remove inappropriate specialties such as Podiatrists, Ambulance Providers, Pathologists and so on.

While, the first month of HEDIS season is here and almost gone there is still time to adequately prepare for success.  Focus on the immediate goals — extract and share data with your software vendor, ensure that you get your CAHPS® sample frame to your auditor and survey vendor by the deadline, and get ready to launch!

Do you have a HEDIS best practices experience you would like to share? Contact me at vandna.pandita@advantmed.com.  I am happy to discuss your HEDIS experiences and needs.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).