medicare advantage special needs plans - crowell & moring– evidence of eligibility for...

(c) Crowell & Moring LLP 2010. All Rights Reserved.

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John GormanCEO, Gorman Health Group

Bruce Tavel

Counsel, Crowell & Moring LLP

February 4, 2009

Medicare Advantage SpecialNeeds PlansThe Future is Now—What You Need to Know

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Agenda

Welcome and Introductions

Special Needs Plans Overview

Key Legal and Regulatory Challenges Facing SpecialNeeds Plans

How Can Medicare Advantage Organizations Ensurethat Special Needs Plans are “Special”

Future of Special Needs Plans

Q & As

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Special Needs Plans Overview

Authorized under Section 231 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Section 231(b) Section 1859(b) (42 U.S.C. 1395w-29(b)), is amended by adding at the end the following new paragraph:

``(b) SPECIALIZED MA PLAN FOR SPECIAL NEEDS INDIVIDUALS DEFINED. -- Section 1859(b) (42 U.S.C.1395w-29(b)) as amended by section 221(b) is amended by adding at the end the following new paragraph:

(6) SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS. –

(A) IN GENERAL. --The term `specialized MA plan for special needs individuals' means an MA plan

that exclusively serves special needs individuals (as defined in subparagraph (B)).

(B) SPECIAL NEEDS INDIVIDUAL. --The term `special needs individual' means an MA eligible

individual who--

(i) is institutionalized (as defined by the Secretary);

(ii) is entitled to medical assistance under a State plan under title XIX; or

(iii) meets such requirements as the Secretary may determine would benefit from enrollment in

such a specialized MA plan described in subparagraph (A) for individuals with severe or

disabling chronic conditions.

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Special Needs Plans Overview (Cont’d)

Sec. 231(c) RESTRICTIONS ON ENROLLMENT PERMITTED.—Section 1859 (42 U.S.C. 1395w-29) is amended by adding at theend of the following new subsection:

“(f) RESTRICTION ON ENROLLMENT FORSPECIALIZED MA PLANS FOR SPECIAL NEEDSINDIVIDUALS. – In the case of a specialized MA plan forspecial needs individuals (as defined in subsection(b)(6)), notwithstanding any other provision of this partand in accordance with regulations of the Secretary andfor periods before January 1, 2009, the plan mayrestrict the enrollment of individuals under the planto individuals who are within one or more classes ofspecial needs individuals.”

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Under MMA, the authority to offer SNPs was scheduled toexpire December 31, 2008.

Medicare, Medicaid, and SCHIP Extension Act of 2007extended the authority until December 2009.

Medicare Improvements for Patients and Providers Act of 2008extended the authority until 2010.

Will the 111th Congress provide a permanent solution?

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Types of Special Needs Plans

– Dual Eligible (D-SNP)

Eligible beneficiaries must be enrolled in Medicare and Medicaid.

CMS permits D-SNPs to limit enrollment to specific subsets (i.e., all dual eligibles, full dualeligibles, zero cost sharing dual eligibles, and Medicaid subset based on coordination withState Medicaid program).

– Severe or Disabling Chronic Condition (C-SNP)

Eligible beneficiaries must have one or more co-morbid and medically complex chronicconditions that are substantially disabling or life threatening, have a high risk ofhospitalization or other significant adverse health outcomes and require specializeddelivery systems across domains of care. (Effective January 1, 2010)

– Institutional (I-SNP)

Eligible beneficiaries must reside or be expected to reside for 90 days or longer in a long-term care facility (skilled nursing facility, nursing facility, intermediate care facility for thementally retarded or an inpatient psychiatric facility).

Reside in the community but meet institutional level of care requirements.

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SNPs are Medicare Advantage plans offered byMedicare Advantage organizations.

Most Medicare Advantage requirements apply toSNPs.

CMS pays the same for SNPs and other MedicareAdvantage plans.

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Special Needs Plan Overview (Cont’d)

From 2006 to 2008:

– 176% increase in SNPplans

– Over 1700% increase inChronic SNP enrollment

From 2008 to Jan. 2009:

– 8% decrease in SNP plans

Courtesy of Gorman Health Group

Special Needs Plans ComprehensiveReport, CMS, Jan. 2009.

Trend in Special Needs Plan Types

0

50

100

150

200

250

300

350

400

450

500

2006 2007 2008 2009 (Jan.)

Dual Eligibles Chronic Institutional

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Special Needs Plans OverviewNumber of SNPs (Cont’d)

Chronic or Disabling Condition (209)

Dual-Eligible (406)

Institutional (83)

Total: 698CMS Special Needs Plan Comprehensive Report, Jan. 2009

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Special Needs Plans OverviewNumber of SNP Members (Cont’d)

Chronic or Disabling Condition (267,881)

Dual-Eligible (907,493)

Institutional (125,549)

Total: 1,300,923

CMS Special Needs Plan Comprehensive Report, Jan. 2009

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Key Legal and Regulatory Challenges:Scrutiny

Special Needs Plans have been subject to increased scrutiny byCongress, CMS & Advocacy Groups.

Why?

– Significant growth in number of SNPs and members

– Vulnerable populations

– Enrollment flexibility (especially for duals and institutionalbeneficiaries)

– CMS payments are greater (payment methodology is the samebut SNP members tend to be sicker)

Takeaway: Expect scrutiny to continue in 2009 and 2010.Provide Congress with a reason to reauthorize SNPs.

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Key Legal and Regulatory Challenges:Enrollment

Moratorium on new disproportionate SNPs. Existingdisproportionate SNPs may enroll non-special needsbeneficiaries as long as a greater proportion of specialneeds individuals than occur nationally in the Medicarepopulation.

Disproportionate SNPs “have proliferated”*

CMS information shows that a significant number of D-SNPs have between 25-40% of enrollment composed ofnon-special needs beneficiaries.*

* 73 Fed. Reg. 28558 (May 16, 2008)

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Key Legal and Regulatory Challenges:Enrollment (Cont’d)

Effective January 1, 2010 Medicare Advantage organizations offering SNPscan only enroll beneficiaries with a qualifying special need (i.e., dual eligible,chronic condition or institutionalized).

SNP cannot disenroll a non-special needs beneficiary who was appropriatelyenrolled in a disproportionate SNP.**

Takeaway: If currently offer a disproportionate SNP, will need toconsider alternative strategies for marketing to spouses. Confirmingspecial needs status at enrollment becomes more important.

** 74 Fed. Reg. 1496 (Jan. 12, 2009)

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Medicare Advantage organizations must confirm special needs status. See MedicareManaged Care Manual, Ch. 2 § 20.11. CMS will also require Medicare Advantageorganizations to employ a process approved by CMS to verify eligibility. See 74 Fed.Reg. 1497-1498.

– Important issue for CMS: “We are strongly committed to ensuring that SNPs carry out proper verification of alleligibility criteria, consistent with the requirements discussed above concerning SNP enrollment requirements.”74 Fed. Reg. 1497 (Jan. 12, 2009).

– Unique operational challenges for each type of SNP:

Chronic Condition SNPs:

– May verify by (i) contacting provider’s office to obtain verification prior to enrollment or (ii) use a CMS-approved pre-enrollment qualification assessment tool prior to enrollment and obtain verification of the condition from provider’soffice on post-enrollment basis. See Medicare Managed Care Manual, Ch. 2 § 20.11.

– Difficult to confirm chronic condition with provider’s office. CMS acknowledged this challenge: “[w]e have heard fromsome organizations that occasionally a provider or the provider’s office is unwilling or unable to provide the requestedconfirmation of an individual’s special needs status on a timely basis.” CMS will review alternative proposals on acase-by-case basis. See Memo from Teresa DeCaro and Anthony Culotta to Medicare Advantage Organizations,October 21, 2008.

Takeaway: If existing verification processes are not working, considersubmitting a proposal to CMS. October 21st memo includes specificproposal requirements.

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Dual Eligible SNPs:

– Must verify Medicaid eligibility. Verification may be by a currentMedicaid card, letter from the state agency that confirms eligibilityor verification through a system query to a State eligibility datasystem.

– Evidence of eligibility for Medicare Part D Low Income Subsidy orother Medicaid status flag in CMS systems not acceptable.

– Must verify continuing eligibility at least as often as the StateMedicaid agency conducts re-determinations. See MedicareManaged Care Manual, Ch. 2 § 20.11.

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– Medicare Advantage organization must generally provide a “deemed”enrollment period of at least 30 days. See Medicare Managed CareManual Ch. 2 § 50.2.5.

» Must provide at least 30 days advance notice of the effective date ofdisenrollment if State Medicaid Agency retroactively disenrolls beneficiary.

» During the deemed enrollment period, the D-SNP must “charge thedeemed-eligible member the same premium and cost-sharing thatwas stipulated in the original enrollment agreement…It is the SNP’sresponsibility to protect members in the period of deemed continuedeligibility by either: informing contracting providers to look to theSNP for payment of any copayments (now due because of loss ofMedicaid eligibility), or informing contracting providers to forgo theco-pays during this period. SNPs must have language to supportthis in its contract with providers.” (emphasis added.) See CMS2009 Call Letter, p. 35

Takeaway: Must understand the State Medicaid re-determinationprocess. Regularly confirm continuing eligibility to reduce risk ofretroactive disenrollment by State Medicaid Agency.

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Institutional SNPs:

– Must verify that beneficiary requires an institutional level of care(“LOC”) and the need for this level of care has lasted 90 days orlonger.

– Can also enroll beneficiaries who have not been institutionalizedfor 90 days if a needs-assessment is conducted that shows that abeneficiary’s condition makes it likely that they will require aninstitutional level of care for 90 days or longer. See MedicareManaged Care Manual, Ch. 2 § 20.11.

– May enroll a beneficiary who resides in the community if thebeneficiary requires an institutional level of care (“institutional-equivalent individual”).

» MIPPA requires that MA organizations use a State assessment toolto confirm the institutional level of care (effective January 1, 2010)

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– The assessment tool must be conducted by a third party. CMSexplains “[w]e believe this entity must be both impartial and havethe requisite professional knowledge to accurately identifyinstitutional LOC [level of care] criteria.” 74 Fed. Reg. 1496 (Jan.12, 2009). Draft 2010 Call Letter (withdrawn) provides additionalrequirements.

Takeaway: If enroll community based beneficiary, must identify LOC

assessment tools and independent third parties to conductassessments. Must implement on a state-by-state basis.

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Key Legal and Regulatory Challenges:Model of Care

Model of Care

– Requirements included in 2008 and 2009 Call Letters.

– Additional requirements included in MIPPA and Final Rule. MIPPA andthe Final Rule must be read together. Preamble to the Final Ruleprovided:

“We believe that [the] combination of MIPPA’s statutory elements andour regulatory prescription for the SNP model of care establishes thestandardized architecture for effective care management, yet givesplans the flexibility to design the unique services and benefits thatenable them to meet the identified needs of their target population.” 74Fed. Reg. 1498 (Jan. 12, 2009) (Final Rule).

– Appropriate network of providers. (MIPPA)

– Comprehensive initial health risk assessment (within 90 days ofenrollment) and annual reassessment of the physical, psychosocial, andfunctional needs of the member. (MIPPA)

– Care plan for each member that addresses goals and objectives,services, and benefits and measurable outcomes. (MIPPA)

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Key Legal and Regulatory Challenges:Model of Care (Cont’d)

– Interdisciplinary team to manage care. (MIPPA)

– Have appropriate staff (employed, contracted, or non-contracted)trained on the SNP model of care to coordinate and/or deliver allservices and benefits. (Final Rule)

– Coordinate the delivery of care across healthcare settings,providers, and services to assure continuity of care. (Final Rule)

– Coordinate the delivery of specialized benefits and services thatmeet the needs of the most vulnerable beneficiaries among thetargeted population. (Final Rule)

– Coordinate communication among plan personnel, providers, andmembers. (Final Rule)

Takeway: At their core, SNPs add value through the developmentand implementation of a robust care management program. Createa thoughtful and compliant program. It will be audited by CMS.

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Key Legal and Regulatory Challenges:D-SNP Issues

– Contracting with State Medicaid Agency

Most common criticism of D-SNPs—that a contract with the State Medicaid Agency isrequired to integrate Medicare and Medicaid services. MedPAC Report to Congress:

“[w]e see that many SNPs are not taking advantage of the opportunityto better coordinate care for special needs beneficiaries…we do not see howdual-eligible SNPs that do not integrate Medicaid could fulfill the opportunity tocoordinate the two programs.” MedPAC Report to the Congress, June 2007,p. 71.

– CMS encourages integration CMS established the Integrated Care Institute

( www.cms.hhs.gov/IntegratedCareInst)

MIPPA requires integration for new D-SNPs and those seeking to expand their servicearea in 2010

– Sec. 164 of MIPPA provides that D-SNPs must have a contract with a StateMedicaid Agency “ to provide benefits, or arrange for benefits to be provided, forwhich such individual is entitled to receive as medical assistance under title XIX[Medicaid]. Such benefits may include long-term care services consistent with Statepolicy.” Effective January 1, 2010.

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Key Legal and Regulatory Challenges:D-SNP Issues (Cont’d)

– CMS appears to provide some latitude. The Interim Final Rule providesthat a contract with a State Medicaid agency means a “formal writtenagreement between an MA organization and the State Medicaid agencydocumenting each entity’s roles and responsibilities with regard to dual-eligible individuals.” 73 Fed. Reg. 54228 and 54248 (to be codified at 42C.F.R. § 422.107(a). (Sept. 18, 2008). Contract must include:

» The Medicare Advantage organization’s responsibility, including financialobligations, to provide or arrange for Medicaid benefits.

» The categories of eligibility for dual-eligibles to be enrolled under the D-SNP.

» The Medicaid benefits covered under the SNP.

» The cost-sharing protections covered under the SNP.

» The identification and sharing of information on Medicaid providerparticipation.

» The verification of enrollee eligibility for Medicare and Medicaid.

» SNP’s service area.

» The contract period.

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Key Legal and Regulatory Challenges:D-SNP Issues (Cont’d)

– How will States respond?

» Mathematica Policy Research’s study, “Evaluation of MedicareAdvantage Special Neesds Plans,” provided that “State attitudestoward SNPs ranged from enthusiasm to indifference, with varyingdegrees of selective interest in between.”

Takeaway: Begin discussions with State Medicaid Agencies assoon as possible. Pipeline for contracting with State MedicaidAgency may be long and limited by state procurementrequirements or other state limitations. Even existing D-SNPsthat will not expand in 2010 may wish to begin a dialogue withthe State.

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Key Legal and Regulatory ChallengesD-SNP Issues (Cont’d)

– Payment of cost-sharing

Sec. 165 of MIPPA provides that a D-SNP “may not impose cost-sharing that exceeds theamount of cost-sharing that would be permitted with respect to the individual under titleXIX [Medicaid] if the individual were not enrolled in such plan.”

Final Rule expands the requirement to all Medicare Advantage plans with dual eligiblemembers and provides specific requirements. The rule provides that “[f]or all MAorganizations with enrollees eligible for both Medicare and Medicaid, specify in contractswith providers that such enrollees will not be held liable for Medicare Part A and B costsharing when the State is responsible for paying such amounts, and inform providers ofMedicare and Medicaid benefits, and rules for enrollees eligible for Medicare andMedicaid. The MA plans may not impose cost-sharing that would be permitted withrespect to the individual under title XIX if the individual were not enrolled in such aplan. The contracts must state that providers will – (A) Accept the MA plan payment aspayment in full, or (B) Bill the appropriate State source.” (Emphasis added.) 74 Fed. Reg.1499-1500 and 1542 (to be codified at 42 C.F.R. § 422.504(g)(1)(iii)). Effective January 1,2010.

Takeaway: How will providers react? Develop a contractingstrategy.

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Key Legal and Regulatory Challenges:C-SNP Issues

Chronic SNPs –

– New definition

Under the MMA there is no specific definition. CMS explained: “[b]ecause thisis a new ‘untested’ type of MA plan, we are not setting forth in regulation adetailed definition of severe and disabling chronic condition that might limitplan flexibility.” 70 Fed. Reg. 4596 (Jan. 28, 2005).

Some criticism of the types of C-SNPs approved by CMS.

Sec. 164 of MIPPA provided a definition of severe or disabling chroniccondition individuals: “have one or more comorbid and medically complexchronic conditions that are substantially disabling or life threatening, have ahigh risk of hospitalization or other significant adverse health outcomes, andrequire specialized delivery systems across domains of care.”

MIPPA also required that the Secretary of Health and Human Servicesconvene a panel of clinical advisors to determine the chronic conditions thatmeet the definition.

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Key Legal and Regulatory Challenges:C-SNP Issues (Cont’d)

– The 2008 Special Needs Plan Chronic Condition Panel identified 15chronic conditions that meet the definition of severe or disabling.

Chronic and disabling mental healthconditions

Chronic lung disordersDiabetes mellitus

StrokeDementia

Certain neurologic disordersChronic hear failure

HIV/AIDSCertain cardiovascular disorders

Certain hematologic disordersCancer (excluding pre-cancerconditions)

End-stage renal disease requiringdialysis

Certain auto-immune disorders

End-stage liver diseaseChronic alcohol and other drugdependence

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Key Legal and Regulatory Challenges:C-SNP Issues (Cont’d)

– Report provided that beginning January 1, 2010, C-SNPs can only offer a plan benefit package (PBP) thatcovers one of the 15 chronic conditions.

– CMS may provide some flexibility. The Draft 2010 CallLetter (withdrawn) provided some flexibility to offer multiple-condition C-SNPs.

Takeaway: Await additional CMS guidance and consider strategy if

currently offer a C-SNP that cannot be renewed in 2010.

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Key Legal and Regulatory Challenges:I-SNP Issues

– Must have contract with long-term care facilities. I-SNPsmust address certain matters in the long-term care facilitycontract or provider manual/P&P if the contract specificallyrefers to the manual or P&P provision.

If a facility chain, must identify each participating facility.

The facility must provide SNP’s clinical staff with appropriate accessto the SNP’s members.

SNP must provide care management protocols to facility.

Delineation of services to be provided by SNP and facility.

Training plan so facility staff understand their responsibility under theSNP model of care.

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Key Legal and Regulatory Challenges:I-SNP Issues (Cont’d)

Procedures for facility to maintain a list of credentialed SNP clinicalstaff in accordance with the facility’s responsibilities under theMedicare Conditions of Participation.

Contract must be for the contract year (through December 31).

Termination clause must clearly state any grounds for earlytermination. of the contract. The contract must include a clear planfor transitioning the enrollee should the contract terminate

See 2008 CMS Call Letter, p. 48-49.

Takeaway: Confirm contracts include all required provisions. CMS will

audit for compliance.

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Cut to the Chase!

The future of SNPs is about twothings:

– “Level playing field”

• MA vs. FFS reimbursement

• SNPs will have little insulation

– VALUE and ACCOUNTABILITY

• SNPs must change the perception thatthey add no value to Medicare and thehealth care system

• SNPs are “canary in the coalmine” fornew regulatory environment

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How Can SNPs Ensure They Are “Special”?

Meet And Exceed CMS Requirements

Demonstrate Results

Ensure You’re Financially Viable

Get Involved In DC And Tell YourStory

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2008 HEDIS

CMS contracted with NCQA to evaluate SNPs. The evaluation includes collection ofSNP specific HEDIS measures as well as structure and process measures.

SNPs were required to report these HEDIS measures by June 2008:

• Colorectal Cancer Screening*

• Glaucoma Screening in Older Adults

• Use of Spirometry Testing in the Assessment and Diagnosisof COPD

• Pharmacotherapy of COPD Exacerbation**

• Controlling High Blood Pressure*

• Persistence of Beta Blocker Treatment After a Heart Attack

• Osteoporosis Management in Older Women

• Antidepressant Medication Management

• Follow-Up After Hospitalization for Mental Illness

• Annual Monitoring for Patients on Persistent Medications

• Potentially Harmful Drug-Disease Interactions

• Use of High Risk Medication in the Elderly

• Board Certification * SNP benefit packages under PPO Contracts do not have to report these measures becausethese measures rely on medical record review.

** This first-year measure is optional for all MA reporting, including the SNP benefit packages.

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2008 HEDIS

477 SNPs reviewed

October 6 – NCQA announced it completedevaluation of SNP Structure and Processmeasures

Evaluation results inconclusive

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HEDIS – 2009 and 2010

2009

– Expect NCQA to provide timeline and requirements incoming weeks

– Review 787 SNPs

Expand suite of HEDIS measures, with focus on measures of care forolder adults

Integrate CAHPS, HOS

Expand structure and process measures to include care transitions,plan design, caregiver experience

Test benchmark measures

2010

– Review 787+ SNPs

– Refine benchmark measures for collection; expand set of applicableHEDIS measures

Source: Presentation by Margaret OSource: Presentation by Margaret OSource: Presentation by Margaret O’’’Keefe, President, NCQAKeefe, President, NCQAKeefe, President, NCQA

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Meet and Exceed CMS Requirements:Annual NCQA SNP Assessments

Be prepared – these reviews will help determineSNP reauthorization

– SNP 1: Complex Case Management

Documented process for identifying members for complex casemanagement

Specific criteria used to identify members eligible for complex casemanagement

Case management procedures

Sample case management reports

Documentation demonstrating how the organization:

– Provides program information to eligible members; and

– informs and educates practitioners

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Meet and Exceed CMS Requirements:Annual NCQA SNP Assessments

SNP 2: Improving Member Satisfaction

– Documentation demonstrating an evaluation of membercomplaint and appeal data

– Documentation demonstrating identification of opportunitiesfor improvement, actions taken, and sharing of results withpractitioners and providers

SNP 3: Clinical Quality Improvements

– Documentation that demonstrates:

The SNP identified at least three meaningful clinical issues; and

The SNP selected three clinical measures that are relevant to itsmembership

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Demonstrate Results

Care and case management

– Measurable improvements in quality of life?

– Improvements in quality of care?

– Clinical etiology of PMPM cost trends

– Integration of medical and drug benefits

– Benefit vs. cost of medical management interventions

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Ensure You’re Financially Viable:MA Phasedown to 100% FFS and Impact on Plans

Depends on the period of the phase out

5 year phase out (CHAMP included 3 years)

Gorman estimates: -$17B reduction by 2014 in the national MAbenchmark

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What a “Level Playing Field” Means

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What a “Level Playing Field” Means: RosierPicture in California Due to Efficiencies

$600

$700

$800

$900

$1,000

$1,100

$1,200

$1,300

2009 2010 2011 2012 2013 2014

Aggregate PMPM Impact, Orange County, CA, of a Benchmark Phase Downto 100% of FFS, Weighted by October, 2008 Enrollment.

FFS, @ 5.5% inflator Benchmark, current law, @ 5.5% inflator Benchmark, phased to 100% FFS

3.3

%

4.2

%

4.2

%

4.2

%

4.2

%

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What a “Level Playing Field” Means: RosierPicture in California Due to Efficiencies

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Geography Matters

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Impact of MA Cuts to Plans

Plan specific impact – depends on the county rate

Many plans will have a reduction in their annualincrease over the phase out period

Plans in counties with the highest MA rates comparedto Medicare FFS will have a net cut in their rates

– Albany with a MA rate of 140% of FFS would havea net reduction each year and -2.1% by 2014

Zero/lowZero/low--premium plans will have little insulationpremium plans will have little insulation

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Manage Your Revenue Aggressively

Must be #1 priority for SNPs.

Within next 4 years expect MA $ ~ 100%FFS; can’t leave money on table due topreventable errors

Compliance and finance collide in revenuemanagement

– Coding intensity audits on HCCs

– Manual requirements on enrollment/PDEreconciliation

Consider MA Revenue Managementfunction to reduce execution risk andimprove performance

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Full Potential of Risk Adjustment Yet to be Realized

1. Retrospective ChartReview capturing whatis in the chart but not

in a claim

2. Substantiation makingsure what is in a RAPS

submission issupported in the chart

3. Prospective Evaluationcapturing what is “in

the member” andmaking sure it gets

into a RAPS

Risk-Adjusting Claims Data

Managing Exposure

Managing the Patient, theRisk, and Your Liability via

Patient Assessment

The Future of HCC Management

PotentialPotentialYield:Yield:

$1,000$1,000--1,6001,600PMPYPMPY

PotentialPotentialYield:Yield:

$3,600 PMPY$3,600 PMPY

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Sources of RAPS Submissions

SOURCE TOTALYIELD

YIELD/CHART COST ROI AUDITRISK

Claims High Low Low High High

Chart review High Moderate Moderate High Moderate

Prospectiveevaluation

Veryhigh

Very high HighVeryhigh

Very low

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Prospective Evaluation in Medicare AdvantagePrograms

Your members must be regularly and completely evaluated byqualified providers who understand Medicare Advantage andrisk adjustment

Complete evaluation should be a plan benefit and part of caremanagement

– In its January 2008 call letter, CMS said that“any MA eligible population should have healthassessments to effectively manage preventive services,diagnostic testing, and therapies.”

The evaluation must incorporate HEDIS measuresand published standards of care

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What is the Potential in Prospective Evaluation?

When a diabetic with a foot ulcer goes to a podiatrist

Dr. Smith250.00 0.20

707.14 0.484

RAF 0.684

Dr. Jones250.70 0.764

250.60 0.0443.71 0.0

357.2 0.268707.14 0.484

RAF 1.516

Difference in payment between Dr. Smith and Dr. Jones $ 0

Difference in payment to the plan (PMPY $600 base) $10,915

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Steps in a Prospective Program

Member Selection

Evaluator Selection

Evaluation

Data Collection

Feedback

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The 2008 Coding Intensity Pilot Audit

Launched with five H numbers from fivedifferent plans

Blues plan, two major MA plans, large planwith primarily commercial book, providerowned plan

Average contract size ~20,000 members

Audit size 200 members with ~750 HCCs

Exposure of ~$130-150,000 for each codenot verified

Pilot expanded to 80 more plans inNovember 2008

Significant recoveries expected, but notuntil 2010

Audit results expected to influence 2010benchmarks

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Making Sure What Is In A RAPS Submission IsSupported In The Chart

About 80% of codes in RAPS come from claims submitted by physicians

But the claim is really a proxy for a chart entry and the assumption isthat there will be documentation in a form acceptable to CMS for everycode submitted in RAPS

That assumption is true about 70% of the time because of:

Missing chart

Non-qualified providers

Unsigned, undated, or illegible notes

Coding errors

Typos

Your chart reviews must capture systemic errors indocumentation so you can correct them before you

are audited.

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2007 Part D Reconciliation Results

39%

61%

Receivable from CMS

Payable to CMS

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2007 Part D Reconciliation Results

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Enrollment Drives Your Business Success

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Keys to Success

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Process Evaluation Importance

Commercial Modeling Mistake

Custom builds are often Pre-Part DArchitecture

Red-headed stepchild syndrome

Growing Data/Transaction responsibility

Growth in eligibles will continue to testweaknesses in current “plumbing”

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What is the Future of SNPs?

Expect significant consolidation and attrition among SNPsover next 4 years.

Only strong will survive -- if program is reauthorized.

– 2008 NCQA evals inconclusive

– 2009 reviews critical to reauthorization.

C-SNPs will coalesce around handful of conditions.

DE/I-SNPs will be hampered by state Medicaid programs incrisis and disarray.

SNPs could play significant role in Medicare and health reformif they can demonstrate value.

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Questions and Answers

Q&A

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How To Reach Us

Bruce O. Tavel, Esq.

Crowell & Moring LLP

1001 Pennsylvania Avenue, NW

Washington, DC 20004-2595

Telephone: (202) 624-2961

Facsimile: (202) 628-5661

Email: [email protected]

John K. Gorman

Chief Executive Officer

Gorman Health Group

2176 Wisconsin Avenue, NW

Washington, DC 20007

Telephone: (202) 364-8283

Facsimile: (202) 244-8324

Email: [email protected]

medicare advantage special needs plans - crowell & moring– evidence of eligibility for...

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