moneyball for the marketplace - healthcare risk adjustment

Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1

Risk Adjustment

http://bit.ly/RiskAdjust



Moneyball for the

MarketplaceDriving success through people, process and

technology


What Is Moneyball for the marketplace

The application of Moneyball business principles for health plans who submit Edge Server data for their Marketplace products

An approach by which plans gain greater insight into the risk of their membership, drive efficiencies and ensure program SME support

A mechanism to ensure revenue integrity and closing care gaps in the face of change and uncertainty


What It Is Not …. A way for health plans to financially “game” the system through fraud

A way for health plans to circumvent rules and regulations

A way for health plans to simply generate more Marketplace revenue


What are the Moneyball principles?

For the purposes of the Marketplace and Edge Server reporting we will focus on the following

OperationalRoot causes analysis of data submission trendsFinancialDetermine HCC opportunities through gap closure and other interventionsTe

chno

logy

Proc

ess

No more spreadsheetsAvoid “Analysis Paralysis”

Peop

le

Don’t leave this to IT or your actuaries….risk adjustment SMEs are an absolute must


What are the Moneyball principles?

Complete, deep understanding of your membership, Edge Server submissions and risk adjustment analytics is the key

Big data, small data

Efficiencies are mission

critical

More bodies, more spreadsheets and your data warehouse do not

equal operational efficiency

SMEs = your Edge

Server manager

You need dedicated, knowledgeable guides to navigate the near-constant CMS changes

For the purposes of the Marketplace and Edge Server reporting we will focus on the following:


What’s at Stake?

Increased internal costs

Experiencing revenue leakage

Having to pay out

Jeopardized program solvency

Impacted plan design and QHP pricing

Inability to close care gaps


Implications of Inaccurate Coding

All conditions coded appropriately

Some conditions coded with poor specificity

No conditions coded

76 year female 0.468



Medicaid eligible 0.177



DM w/vascular CC(HCC 15) 0.608

DM w/vascular CC(HCC 19) 0.181

DM not coded

Vascular w/CC(HCC 104) 0.645

Vascular w/CC(HCC 105) 0.324

Vascular not coded

CHF(HCC 80) 0.396

CHF not coded CHF not coded

Disease interaction No disease interaction No disease interaction

Total RAF 2.497 Total RAF 1.15 Total RAF 0.645

PMPM $1873 PMPM $863 PMPM $484

Annual payment $22,473

Annual payment $10,350

Annual payment $5805

***CC- Chronic Condition RAF-Risk Adjustment Factor PMPM- Per Member Per Month


Edge Server submission gaps

Manual reviewsaffect autoAdjudicationrates

Gap 1No automatedprioritization ofpended claims

Gap 4Timely filingmisalignment

Gap 3Edits are notAligned

Gap 2

Claims

Reference data

XML Report

Report

Report

Multi-tier rejects

Complex reject management

XML

XMLCoding claims from patient chart

Chart Claims

Edge Server CMS


Provider Education & Engagement

Risk adjustment and quality webinars

Targeted listsDashboards

via self-service portal

Telephonic outreach

On-site risk adjustment and quality education

Provider alerts

Coding Gaps Closed


Next Steps

Learn More Watch Recorded webinarhttp://bit.ly/RiskAdjust

[email protected]



mailto:[email protected]

mailto:[email protected]

moneyball for the marketplace - healthcare risk adjustment

Healthcare