Advantmed Advances Payer Understanding and Preparation for 2019 Medicare Advantage and Part D Rate Announcement and Call Letter, Issues Fact Sheet

Santa Ana, CA — April 12, 2018 — Responding to the recent release of the 2019 Medicare Advantage and Part D Rate Announcement and Call LetterAdvantmed, LLC, an integrated risk-adjustment optimization and quality improvement company, announces the release of its Fact Sheet, highlighting key points to help Medicare Advantage (MA) plans to understand the implications and prepare for these changes.

“MA plan capabilities related to reimbursement, medical cost management, and risk adjustment must be responsive to CMS changes,” says Jay Baker, senior vice president, quality and risk adjustment solutions. “Advantmed recognizes that this is not always a simple undertaking and will lend its expertise to MA plan leaders who can benefit from our experience.”

Highlights 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.

“A process should be in place to gather and report encounter data, while quickly troubleshooting submission issues,” Baker adds. “Adjusting to these changes will require specialized expertise because adjustments will impact plan performance, patient care, and compliance. Successful health plans and provider-sponsored organizations must integrate risk-adjustment strategies to meet growing regulatory and market demand for care quality that leads to better patient outcomes.”

About Advantmed, LLC

Advantmed, LLC is a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs.  Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members.  For more information on Advantmed’s solutions visit www.advantmed.com.

Advantmed Physician Record Reviews: Medicare Advantage Plans Gain Clinical Insights for Risk-Adjusted Conditions and Quality/Care Management Opportunities, Impact HCC Coding & CMS Reimbursement

Santa Ana, CA — February 14, 2018 — Advantmed, LLC, an integrated risk-adjustment optimization and quality improvement company, today introduces Physician Record Review (PRR), a two-stage retrospective chart review process, first by a certified coder and second with a board-certified physician. This empowers Medicare Advantage (MA) plans with clinical insight into risk adjusting conditions to enhance traditional analytical platforms.

“The ability of physicians to review progress notes for primary care, specialists’ hospital charts, radiology and laboratory results not routinely used in standard analytics provides for more demonstrable actionable information,” says Nilay Shah, president of Provider Solutions, Advantmed. “Additionally, PRR identifies care opportunities in accordance with evidence-based medicine. The Advantmed physician staffs are board-certified in their area of specialty with extensive risk-adjustment training to uncover the potential for risk-adjusting conditions not identified by current programs.”

Shah says that PRRs represent one of the best opportunities to focus on Hierarchical Condition Categories (HCCs), explaining, “Our team of physician reviewers identifies HCCs within each patient chart, annotates risk adjustable conditions by page number, and integrates these outputs into a broader array of activities.”

CMS uses HCCs to reimburse MA plans based upon the health of their members. It pays for the predicted cost expenditures of patients by adjusting those payments based on demographic information, Medicaid status and the severity of illness or patient health status as recorded in medical record documentation.

“Advantmed PRRs also confirm the previous two years of submitted HCCs for clinical confirmation not currently submitted in the calendar year,” says Shah. “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.”

Advantmed received certification from The National Committee for Quality Assurance (NCQA) for 2018 HEDIS measures for the 12thconsecutive year. Read more here.

About Advantmed, LLC

Advantmed, LLC is a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs.  Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members.  For more information on Advantmed’s solutions visit www.advantmed.com.