Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps - PowerPoint Presentation

Error Correction for Risk Adjustment Submissions Workshop: Preparing for Sweeps August 1, 2019 Transforming Risk Adjustment Through Insight, Transparency and Control

Welcome Lisa Pouncey Senior Director of Product Management30 Years in Data Management12 Years HealthCare EMR/Billing Systems/Meaningful Use Health Plan Claims Processing 10+ Health Plans — 10 Data Analysts Babel Health Risk Adjustment Submission Platform EDPS/RAPS/MMP Medicaid APCD Data Analytics and Management Tool BPO/Professional Services

Agenda Introduction Defining the Gap Rethinking the Correction Process Top 4 Processing Mistakes That Contribute to Lost Risk Revenue Incorporating Technology and Encounter Workflow for RemediationHow to Tackle the Most Challenging Problems/Errors Q&A and Summary

How to Tackle the Most Challenging Problems/Errors What are your pain points related to sweeps and state recon/quality check points?More errors in your error pool that you can manage Have errors that you don’t know how to resolveAnesthesia claimsNPI (provider issues)Membership eligibilityProvider managementLoss of revenue

Defining the Gap Data Errors Claims Payment Report Outcomes

ERROR POOL can correlate to BIG DOLLARS Members: 30,000 Claims: 6% Can’t Send, 4% Rejected 90% Accepted, 66% Risk Eligible -$5,900,000.00 What’s In It for You?

Updating the End Game Same Place Same Thing Syndrome This is the way we have always done itChanging processes/technology costs money Establish the Reason to Change Prepare a business case comparing cost of changing processes or technology to the cost of not changing Illustrate the cost of repair is greater than the cost of prevention Show Stopper Successful Response

Business Case: Internal

Is it more important to correct a $20,000 claim or$200 claim? IT DEPENDS

Rethink Your Correction Process Prioritize error correction by risk impact and not by dollars paid Easily quantify the error pool to target those that are going to have the most financial impactNeed to clean up every episode and not just one (which is the past approach)

How Do You Prioritize Without a Tool CMS publishes a list of all the procedure codes for risk eligible encounters. Check procedures of the encounters in your error pool against the CMS list.Available via: Click here for a list of procedure codes

CMS Procedure Codes HCPCS/CPT Code Short Description In CY2019 Included List? C5271 Low cost skin substitute app yes C5273 Low cost skin substitute app yes C5275 Low cost skin substitute app yes C5277 Low cost skin substitute app yes C9600 Perc drug-el co stent sing yes C9602 Perc d-e cor stent ather s yes C9604 Perc d-e cor revasc t cabg s yes C9606 Perc d-e cor revasc w ami s yes C9607 Perc d-e cor revasc chro sin yes C9727 Insert palate implants yes

How Do You Prioritize Without a Tool If you can’t cross-check the error pool against CMS procedure codes: Prioritize professional and institutional encounters that are not: Home Health: Bill Type 31X Skilled Nursing: Bill Type 21X Inpatient Rehab: Bill Type 72X-76X Hospice: Bill Type 81X or 82X Transportation: POS 40 or 41Laboratory/Diagnostic Imaging: Bill Type Various 1 2 3 4 56

What to Tackle: Big Bucks vs. Little Bucks Error pool can be broken down into categories of some bucks and no bucks Within the some bucks listing, you want to prioritize between: and Compare against CMS’ HCC (hierarchical condition category list): Diagnosis codes B20, B97 are related to HIVDiagnosis codes that start with C are related to cancerDiagnosis codes that start with D are related to blood and immunity Diagnosis codes that start with E are related to diabetes, malnutrition and weight Diagnosis codes that start with F are related to drug dependency and alcohol abuse Diagnosis codes that start with I are related to heart, kidney and vascular diseaseDiagnosis codes that start with J are related to COPD Diagnosis codes that start with T are related to depressive disorders BIGlittle

Top 4 Processing Mistakes: Lost Revenue Not maintaining current procedure code/procedure code modifier, and not comparing code effective dates to claims dates of service for proper usage. Ranked #1 and #3 respectively in CEDI’s Top 10 errors of January 2019 1 Not loading the MMR into the claims system to validate MBI/HICN assignment, coverage start and end dates and beneficiary’s date of birth. Ranked #2 in CEDI’s Top 10 2 Sourced from 2019 Publications from CMS and National Government Services Common Electronic Data Interchange (CEDI) Incorrect or missing billing provider NPI and EIN. Ranked #4, #5 and #7 in CEDI’s Top 10 3 Inappropriately dated service dates (start/end dates and pay dates don’t align) Ranked #6 and #8 in CEDI’s Top 10 4

Technology and Workflow Response Errors: • Error Category: BeneficiaryError Code(s): 02125Error Details: R: Beneficiary date of birth mismatches with the date of birth listed in MARx database.

CMS Common Edit Data Interchange (CEDI) If you don’t have an error correction system that demystifies the reject reason codes, go to the lookup tool: Click here for a list of reason codes

CMS Common Edit Data Interchange (CEDI) Access the CEDI spreadsheet for explanations of the errors:Learn more about the overall submission process: Click here for an explanation Click here to learn more

How to Tackle the Most Challenging Problems/Errors What are your pain points related to sweeps and state recon/quality check points? More errors in your error pool that you can manageHave errors that you don’t know how to resolve Anesthesia claimsNPI (provider issues)Membership eligibilityProvider managementLoss of revenue

Thank You! lpouncey@babelhealth.com