Description: Medicare-Advantage Organizations (MAOs) are often under intense pressure to increase revenue. The ACA dramatically changed the incentives by which MAOs achieve financial success. With benchmark rates growing only as fast as FFS Medicare rates, many MAOs rely on risk scores and quality bonuses as their primary source of additional revenue.There are a not insignificant number of MAOs that are either under scrutiny by federal investigators, exposed to whistleblower lawsuits, and some even paying large penalties to resolve False Claims Act liability for providing inaccurate risk adjustment information (e.g., $270 million paid by Healthcare Partners/DaVita Medical Holdings in October 2018).Is it possible to operate a risk adjustment program that is both compliant with applicable federal regulations and sub-regulatory guidance yet still generate the revenue to ensure that Medicare-Advantage plans are financially viable in the marketplace? The presenters believe that not only is true compliance (as opposed to the mere appearance of a compliance program) a requirement for success, it is a necessary pre-condition for both MAO profitability and to ensure that risk scores are an accurate representation of member morbidity.

Description: Shared savings deals are all the rage these days. Significant numbers of payers and provider groups in many markets around the U.S. want to engage in shared savings contracts covering commercial, Medicare and Medicaid patients. The fundamental question underlying a value-based contract is, for whom is the value accruing? Ostensibly, value is accruing to the sponsor—whether employer or public payer—but should be accruing to the provider as well. Often design flaws in value-based arrangements and contracts and/or the inability to execute in a value-based paradigm diminish the savings that could have accrued, create inequities in value or drive unintended consequences. This presentation will provide attendees with insights into how to design a workable value-based payment initiative, how to educate both payer and provider participants, and how to oversee the initiative’s operations. Specific topics will include: • Attribution logic: prospective, retrospective and the details in between • Risk adjustment: why one model doesn’t fit all arrangements, and even if it does, how do you implement? • Data and reporting: matching business needs to the payer’s willingness to be transparent and provider capabilities • Quality improvement as a component of payment: actionable and tied to the attributed population or just “out there?”

Description: Risk adjustment in government regulated health plans has been around for over two decades. Yet the strategies for promoting risk score accuracy haven't varied much during that time. Most health plans, physician groups, and vendors promote chart reviews and/or in-home assessments as the primary vehicle for collecting data not perceived to be present in the routine claims submission and adjudication stream. We know that most organizations trying to coalesce encounter data from multiple sources often fail to ensure that all relevant data is ultimately submitted to CMS or a state Medicaid agency. Crucial data, often with significant financial value, frequently gets lost in the data pipeline, somewhere between the provider's billing system and the health plan and/or its vendors. Because 837-formatted data is difficult to read, it complicates payers and vendor’s abilities to track encounter data so that every service delivered to patients is credited to the applicable risk adjustment formula. It is incumbent upon successful risk-adjusted entities to be able to track encounter data, identify processes and/or vendors which may be mangling or losing data, in order to ensure that risk scores are sufficiently accurate to be compliant with plan sponsor requirements and to ensure appropriate revenue to the health plan or provider group.