Edifecs strategies for succeeding in a perfect revenue storm- RISE webinar

Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1

Ensuring Revenue Success with a 1-2 PunchStrategies for succeeding in a perfect revenue storm


Agenda 1. Who is Edifecs?

2. The Perfect Revenue Storm & Success Checklist

3. Solving Real Scenarios

4. Executing Your 1-2 Punch

5. Achieving Value – A Long Term Solution


Innovator in Healthcare IT

“Customer first innovation model, proven by 20 years of reinvesting into new solutions to meet the demands of the radical

transformation impacting healthcare”

Serving more than 215 million lives through our 350+ customers

Smart Trading

Automate data validation

2006

Compliance

Simplify compliance management

2009

Revenue Integrity

Ensuring revenue integrity

2012

Population Payment

Design and operationalizevalue-based contracts

2015

SpecBuilder

Standardize mappingand simplify testing

1996

Worldwide745+ Employees

LeadersIn Trading and Compliance

MultipleFederal Agencies incl. CMS

Top Health Plans

8/9

Care Providers

100

Blue Plans

25/36

Medicaid Programs

25/52


What You Don’t Know Can Hurt You!

HCC Coding

Submission Quality

Submission Timeliness


Perfect Revenue Storm 2016

Submission

Timelin

ess -

2 months l

eft for

2015 data

submiss

ions

HCC Coding - ICD-10 transition &

coding inconsistencies

Submission Quality–

RADV/IVA audits

and coding

comparison

analyses

Submission

Quality-

EDPS/RAPS data

submission for

risk score

calculation

HCC Coding - ICD-10 transition

& coding inconsistencies

Submission

Timeliness

–

ICD-10 support

Marketplace

Medicare Advantage


Have you performed ICD-10 impact assessment on HCC risk adjustment? Yes, we have full understanding of Impact My existing Risk Adjustment vendor will analyze the data for me No, we have not performed an assessment What’s an HCC?

Polling Question 1


Checklist – Your Priorities for Success Review volume of ICD10 claims received in Q4. Identify

any volume gaps at the provider level Compare conditions / case-mixes received throughout

the year and prior years Ensure encounters are submitted and reconciled w/

ability to manage exceptions Calculate estimated risk score of members using ICD9+

ICD10 Compare risk scores to previous year to identify +/-

shifts > x% Report discrepancies to identify root cause (claim

volume, ICD9-10 mismatch, encounter exception issues, etc)

Leverage ICD10 granularity to optimize risk scores


Solving Real Scenarios


Perfect Revenue Storm – ICD-10

Sample Membership : Regional health plan with a membership of 119k members

3 % of membership have

diagnosis codes which

have a variation in HCC

codes between ICD-9 and

ICD-10

30 % of members with

HCC code variations due

to unspecified code usage

in ICD-10

10 % of HCC code loss is

happening due to

combination codes not

coded properly in ICD-10

~ 1% of HCC risk scores

are lost in pregnancy and

new born conditions

between ICD-9 and ICD-10


ICD-9 and ICD-10 Diagnosis codes are linked to hierarchical condition categories (HCCs) which have associated risk factors and that drive member risk scores

ICD-9Diag 1 Diag 2 Diag 3 Diag 4

HCC X1 HCC X2 HCC X3

Member level risk score

Risk Adjusted Payments (CMS MA/HIX RA/ACO)

ICD-10

HCC shift can lower or increase risk score

Revenue impact due to change in payments

HCC Shifts Types:HCC in ICD-10 is HigherHCC in ICD-10 is LowerNo HCC in ICD-9 and HCC in ICD-10HCC in ICD-9 and No HCC in ICD-10

Diag 1 Diag 2 Diag 3 Diag 4

HCC X1 HCC X4 No HCC mapping

Member level risk score

Risk Adjusted Payments (CMS MA/HIX RA/ACO)

Revenue Perfect Storm – ICD-10


Perfect Revenue Storm– Prioritized Exception Management

One health plan managing 500K Marketplace members and 200K Medicare Advantage members

Missed Opportunities

Unable to submit updates/corrections due to issues with internal systems

No discrepancy analysis of what plan considers a risk adjustment diagnosis vs CMS

Missed submission timelines due to delay in prioritizing error corrections

ICD-10 coding errors and potential issues with risk score loss

Rudimentary and unsophisticated processes for exception workflow/correction


Member with high risk conditions/HCC codes

Member approaching RI Limit or exceeded

Members rejected for missing information

Members with invalid coverages

Member

Claims with HCC eligible diagnoses not submitted to

CMS

Claims with HCC variations in ICD-10

Rejected claims with HCC risk diagnoses

Claims with missing membership information

ClaimsPerfect Revenue Storm– Prioritized Exception Management

WatchRecorded webinarStrategies for succeeding in a perfect revenue storm

[email protected]

Be sure to engage with Edifecs at RISE Annual 2016.

Roundtable discussion: 3:45 – 5:00 PM on Monday 3/21. Gain additional, detailed insight into how intelligently managing the ICD-10 transition and implementing prioritized exception workflows can translate into increased revenue!

Edifecs booth: Connect with Edifecs encounter management, risk adjustment and ICD-10 industry experts and get your questions answered!

https://www.edifecs.com/insights/resources/ensuring-revenue-success-with-a-1-2-punch



mailto:[email protected]




We’ll see you at RISE Annual 2016!

Be sure to engage with Edifecs at RISE Annual 2016. How? Here’s the details:

• Roundtable discussion: 3:45 – 5:00 PM on Monday 3/21. Gain additional, detailed insight into how intelligently managing the ICD-10 transition and implementing prioritized exception workflows can translate into increased revenue!

• Edifecs booth: Connect with Edifecs encounter management, risk adjustment and ICD-10 industry experts and get your questions answered!