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Pathways to Partnerships | Bridging Connections For Value edifecs confidential 1
Risk Adjustment
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 2
Moneyball for the
MarketplaceDriving success through people, process and
technology
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 3
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 4
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 5
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 6
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:
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 7
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 8
Implications of Inaccurate Coding
All conditions coded appropriately
Some conditions coded with poor specificity
No conditions coded
76 year female 0.468
76 year female 0.468
76 year female 0.468
Medicaid eligible 0.177
Medicaid eligible 0.177
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 9
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 10
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
Pathways to Partnerships | Bridging Connections For Value edifecs confidential 11
Next Steps
Learn More Watch Recorded webinarhttp://bit.ly/RiskAdjust