Medicare Advantage Special Needs Plans

The Future is Now—What You Need to Know

John Gorman CEO, Gorman Health Group Bruce Tavel Counsel, Crowell & Moring LLP February 4, 2009 (c) Crowell & Moring LLP 2010. All Rights Reserved.

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Agenda  Welcome and Introductions  Special Needs Plans Overview  Key Legal and Regulatory Challenges Facing Special Needs Plans  How Can Medicare Advantage Organizations Ensure that Special Needs Plans are “Special”  Future of Special Needs Plans  Q & As

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Special Needs Plans Overview 

Authorized under Section 231 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Section 231(b) Section 1859(b) (42 U.S.C. 1395w-29(b)), is amended by adding at the end the following new paragraph: ``(b) SPECIALIZED MA PLAN FOR SPECIAL NEEDS INDIVIDUALS DEFINED. -- Section 1859(b) (42 U.S.C. 1395w-29(b)) as amended by section 221(b) is amended by adding at the end the following new paragraph: (6) SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS. – (A) IN GENERAL. --The term `specialized MA plan for special needs individuals' means an MA plan that exclusively serves special needs individuals (as defined in subparagraph (B)). (B) SPECIAL NEEDS INDIVIDUAL. --The term `special needs individual' means an MA eligible individual who-(i) is institutionalized (as defined by the Secretary); (ii) is entitled to medical assistance under a State plan under title XIX; or (iii) meets such requirements as the Secretary may determine would benefit from enrollment in such a specialized MA plan described in subparagraph (A) for individuals with severe or disabling chronic conditions.

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Special Needs Plans Overview (Cont’d) Sec. 231(c) RESTRICTIONS ON ENROLLMENT PERMITTED.— Section 1859 (42 U.S.C. 1395w-29) is amended by adding at the end of the following new subsection: “(f) RESTRICTION ON ENROLLMENT FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS. – In the case of a specialized MA plan for special needs individuals (as defined in subsection (b)(6)), notwithstanding any other provision of this part and in accordance with regulations of the Secretary and for periods before January 1, 2009, the plan may restrict the enrollment of individuals under the plan to individuals who are within one or more classes of special needs individuals.”

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Special Needs Plans Overview (Cont’d)  Under MMA, the authority to offer SNPs was scheduled to expire December 31, 2008.  Medicare, Medicaid, and SCHIP Extension Act of 2007 extended the authority until December 2009.  Medicare Improvements for Patients and Providers Act of 2008 extended the authority until 2010.  Will the 111th Congress provide a permanent solution?

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Special Needs Plans Overview (Cont’d)  Types of Special Needs Plans – Dual Eligible (D-SNP)  Eligible beneficiaries must be enrolled in Medicare and Medicaid.  CMS permits D-SNPs to limit enrollment to specific subsets (i.e., all dual eligibles, full dual eligibles, zero cost sharing dual eligibles, and Medicaid subset based on coordination with State Medicaid program).

– Severe or Disabling Chronic Condition (C-SNP)  Eligible beneficiaries must have one or more co-morbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes and require specialized delivery systems across domains of care. (Effective January 1, 2010)

– Institutional (I-SNP)  Eligible beneficiaries must reside or be expected to reside for 90 days or longer in a longterm care facility (skilled nursing facility, nursing facility, intermediate care facility for the mentally retarded or an inpatient psychiatric facility).  Reside in the community but meet institutional level of care requirements.

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Special Needs Plans Overview (Cont’d)  SNPs are Medicare Advantage plans offered by Medicare Advantage organizations.  Most Medicare Advantage requirements apply to SNPs.  CMS pays the same for SNPs and other Medicare Advantage plans.

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Special Needs Plan Overview (Cont’d) 



From 2006 to 2008: – 176% increase in SNP plans – Over 1700% increase in Chronic SNP enrollment From 2008 to Jan. 2009: – 8% decrease in SNP plans

Trend in Special Needs Plan Types 500 450 400 350 300 250 200 150 100 50 0 2006 Dual Eligibles

Courtesy of Gorman Health Group Special Needs Plans Comprehensive Report, CMS, Jan. 2009.

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2007

2008 Chronic

2009 (Jan.) Institutional

Special Needs Plans Overview Number of SNPs (Cont’d)

Chronic or Disabling Condition (209) Dual-Eligible (406) Institutional (83) Total: 698 CMS Special Needs Plan Comprehensive Report, Jan. 2009

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Special Needs Plans Overview Number of SNP Members (Cont’d)

Chronic or Disabling Condition (267,881) Dual-Eligible (907,493) Institutional (125,549) Total: 1,300,923 CMS Special Needs Plan Comprehensive Report, Jan. 2009

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Key Legal and Regulatory Challenges: Scrutiny  Special Needs Plans have been subject to increased scrutiny by Congress, CMS & Advocacy Groups.  Why? – Significant growth in number of SNPs and members – Vulnerable populations – Enrollment flexibility (especially for duals and institutional beneficiaries) – CMS payments are greater (payment methodology is the same but SNP members tend to be sicker) Takeaway: Expect scrutiny to continue in 2009 and 2010. Provide Congress with a reason to reauthorize SNPs.

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Key Legal and Regulatory Challenges: Enrollment  Moratorium on new disproportionate SNPs. Existing disproportionate SNPs may enroll non-special needs beneficiaries as long as a greater proportion of special needs individuals than occur nationally in the Medicare population.  Disproportionate SNPs “have proliferated”*  CMS information shows that a significant number of DSNPs have between 25-40% of enrollment composed of non-special needs beneficiaries.* * 73 Fed. Reg. 28558 (May 16, 2008)

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Key Legal and Regulatory Challenges: Enrollment (Cont’d) 

Effective January 1, 2010 Medicare Advantage organizations offering SNPs can only enroll beneficiaries with a qualifying special need (i.e., dual eligible, chronic condition or institutionalized).



SNP cannot disenroll a non-special needs beneficiary who was appropriately enrolled in a disproportionate SNP.** Takeaway: If currently offer a disproportionate SNP, will need to consider alternative strategies for marketing to spouses. Confirming special needs status at enrollment becomes more important.

** 74 Fed. Reg. 1496 (Jan. 12, 2009)

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Key Legal and Regulatory Challenges: Enrollment (Cont’d) 

Medicare Advantage organizations must confirm special needs status. See Medicare Managed Care Manual, Ch. 2 § 20.11. CMS will also require Medicare Advantage organizations to employ a process approved by CMS to verify eligibility. See 74 Fed. Reg. 1497-1498. – –

Important issue for CMS: “We are strongly committed to ensuring that SNPs carry out proper verification of all eligibility criteria, consistent with the requirements discussed above concerning SNP enrollment requirements.” 74 Fed. Reg. 1497 (Jan. 12, 2009). Unique operational challenges for each type of SNP: 

Chronic Condition SNPs: – May verify by (i) contacting provider’s office to obtain verification prior to enrollment or (ii) use a CMS-approved preenrollment qualification assessment tool prior to enrollment and obtain verification of the condition from provider’s office on post-enrollment basis. See Medicare Managed Care Manual, Ch. 2 § 20.11. – Difficult to confirm chronic condition with provider’s office. CMS acknowledged this challenge: “[w]e have heard from some organizations that occasionally a provider or the provider’s office is unwilling or unable to provide the requested confirmation of an individual’s special needs status on a timely basis.” CMS will review alternative proposals on a case-by-case basis. See Memo from Teresa DeCaro and Anthony Culotta to Medicare Advantage Organizations, October 21, 2008.

Takeaway: If existing verification processes are not working, consider submitting a proposal to CMS. October 21st memo includes specific proposal requirements.

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Key Legal and Regulatory Challenges: Enrollment (Cont’d)  Dual Eligible SNPs: – Must verify Medicaid eligibility. Verification may be by a current Medicaid card, letter from the state agency that confirms eligibility or verification through a system query to a State eligibility data system. – Evidence of eligibility for Medicare Part D Low Income Subsidy or other Medicaid status flag in CMS systems not acceptable. – Must verify continuing eligibility at least as often as the State Medicaid agency conducts re-determinations. See Medicare Managed Care Manual, Ch. 2 § 20.11.

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Key Legal and Regulatory Challenges: Enrollment (Cont’d) – Medicare Advantage organization must generally provide a “deemed” enrollment period of at least 30 days. See Medicare Managed Care Manual Ch. 2 § 50.2.5. » Must provide at least 30 days advance notice of the effective date of disenrollment if State Medicaid Agency retroactively disenrolls beneficiary.

» During the deemed enrollment period, the D-SNP must “charge the deemed-eligible member the same premium and cost-sharing that was stipulated in the original enrollment agreement…It is the SNP’s responsibility to protect members in the period of deemed continued eligibility by either: informing contracting providers to look to the SNP for payment of any copayments (now due because of loss of Medicaid eligibility), or informing contracting providers to forgo the co-pays during this period. SNPs must have language to support this in its contract with providers.” (emphasis added.) See CMS 2009 Call Letter, p. 35

Takeaway: Must understand the State Medicaid re-determination process. Regularly confirm continuing eligibility to reduce risk of retroactive disenrollment by State Medicaid Agency.

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Key Legal and Regulatory Challenges: Enrollment (Cont’d)  Institutional SNPs:

– Must verify that beneficiary requires an institutional level of care (“LOC”) and the need for this level of care has lasted 90 days or longer. – Can also enroll beneficiaries who have not been institutionalized for 90 days if a needs-assessment is conducted that shows that a beneficiary’s condition makes it likely that they will require an institutional level of care for 90 days or longer. See Medicare Managed Care Manual, Ch. 2 § 20.11. – May enroll a beneficiary who resides in the community if the beneficiary requires an institutional level of care (“institutionalequivalent individual”). » MIPPA requires that MA organizations use a State assessment tool to confirm the institutional level of care (effective January 1, 2010)

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Key Legal and Regulatory Challenges: Enrollment (Cont’d) – The assessment tool must be conducted by a third party. CMS explains “[w]e believe this entity must be both impartial and have the requisite professional knowledge to accurately identify institutional LOC [level of care] criteria.” 74 Fed. Reg. 1496 (Jan. 12, 2009). Draft 2010 Call Letter (withdrawn) provides additional requirements.

Takeaway: If enroll community based beneficiary, must identify LOC assessment tools and independent third parties to conduct assessments. Must implement on a state-by-state basis.

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Key Legal and Regulatory Challenges: Model of Care  Model of Care – –

– – –

Requirements included in 2008 and 2009 Call Letters. Additional requirements included in MIPPA and Final Rule. MIPPA and the Final Rule must be read together. Preamble to the Final Rule provided: “We believe that [the] combination of MIPPA’s statutory elements and our regulatory prescription for the SNP model of care establishes the standardized architecture for effective care management, yet gives plans the flexibility to design the unique services and benefits that enable them to meet the identified needs of their target population.” 74 Fed. Reg. 1498 (Jan. 12, 2009) (Final Rule). Appropriate network of providers. (MIPPA) Comprehensive initial health risk assessment (within 90 days of enrollment) and annual reassessment of the physical, psychosocial, and functional needs of the member. (MIPPA) Care plan for each member that addresses goals and objectives, services, and benefits and measurable outcomes. (MIPPA)

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Key Legal and Regulatory Challenges: Model of Care (Cont’d) – Interdisciplinary team to manage care. (MIPPA) – Have appropriate staff (employed, contracted, or non-contracted) trained on the SNP model of care to coordinate and/or deliver all services and benefits. (Final Rule) – Coordinate the delivery of care across healthcare settings, providers, and services to assure continuity of care. (Final Rule) – Coordinate the delivery of specialized benefits and services that meet the needs of the most vulnerable beneficiaries among the targeted population. (Final Rule) – Coordinate communication among plan personnel, providers, and members. (Final Rule) Takeway: At their core, SNPs add value through the development and implementation of a robust care management program. Create a thoughtful and compliant program. It will be audited by CMS. 20 (c) Crowell & Moring LLP 2010. All Rights Reserved.

Key Legal and Regulatory Challenges: D-SNP Issues – Contracting with State Medicaid Agency  Most common criticism of D-SNPs—that a contract with the State Medicaid Agency is required to integrate Medicare and Medicaid services. MedPAC Report to Congress: “[w]e see that many SNPs are not taking advantage of the opportunity to better coordinate care for special needs beneficiaries…we do not see how dual-eligible SNPs that do not integrate Medicaid could fulfill the opportunity to coordinate the two programs.” MedPAC Report to the Congress, June 2007, p. 71.

– CMS encourages integration CMS established the Integrated Care Institute ( www.cms.hhs.gov/IntegratedCareInst)  MIPPA requires integration for new D-SNPs and those seeking to expand their service area in 2010 – Sec. 164 of MIPPA provides that D-SNPs must have a contract with a State Medicaid Agency “ to provide benefits, or arrange for benefits to be provided, for which such individual is entitled to receive as medical assistance under title XIX [Medicaid]. Such benefits may include long-term care services consistent with State policy.” Effective January 1, 2010.

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Key Legal and Regulatory Challenges: D-SNP Issues (Cont’d) – CMS appears to provide some latitude. The Interim Final Rule provides that a contract with a State Medicaid agency means a “formal written agreement between an MA organization and the State Medicaid agency documenting each entity’s roles and responsibilities with regard to dualeligible individuals.” 73 Fed. Reg. 54228 and 54248 (to be codified at 42 C.F.R. § 422.107(a). (Sept. 18, 2008). Contract must include: » The Medicare Advantage organization’s responsibility, including financial obligations, to provide or arrange for Medicaid benefits. » The categories of eligibility for dual-eligibles to be enrolled under the D-SNP. » The Medicaid benefits covered under the SNP. » The cost-sharing protections covered under the SNP. » The identification and sharing of information on Medicaid provider participation. » The verification of enrollee eligibility for Medicare and Medicaid. » SNP’s service area. » The contract period.

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Key Legal and Regulatory Challenges: D-SNP Issues (Cont’d) – How will States respond? » Mathematica Policy Research’s study, “Evaluation of Medicare Advantage Special Neesds Plans,” provided that “State attitudes toward SNPs ranged from enthusiasm to indifference, with varying degrees of selective interest in between.”

Takeaway: Begin discussions with State Medicaid Agencies as soon as possible. Pipeline for contracting with State Medicaid Agency may be long and limited by state procurement requirements or other state limitations. Even existing D-SNPs that will not expand in 2010 may wish to begin a dialogue with the State.

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Key Legal and Regulatory Challenges D-SNP Issues (Cont’d) – Payment of cost-sharing  Sec. 165 of MIPPA provides that a D-SNP “may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under title XIX [Medicaid] if the individual were not enrolled in such plan.”  Final Rule expands the requirement to all Medicare Advantage plans with dual eligible members and provides specific requirements. The rule provides that “[f]or all MA organizations with enrollees eligible for both Medicare and Medicaid, specify in contracts with providers that such enrollees will not be held liable for Medicare Part A and B cost sharing when the State is responsible for paying such amounts, and inform providers of Medicare and Medicaid benefits, and rules for enrollees eligible for Medicare and Medicaid. The MA plans may not impose cost-sharing that would be permitted with respect to the individual under title XIX if the individual were not enrolled in such a plan. The contracts must state that providers will – (A) Accept the MA plan payment as payment in full, or (B) Bill the appropriate State source.” (Emphasis added.) 74 Fed. Reg. 1499-1500 and 1542 (to be codified at 42 C.F.R. § 422.504(g)(1)(iii)). Effective January 1, 2010.

Takeaway: How will providers react? Develop a contracting strategy.

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Key Legal and Regulatory Challenges: C-SNP Issues  Chronic SNPs – – New definition  Under the MMA there is no specific definition. CMS explained: “[b]ecause this is a new ‘untested’ type of MA plan, we are not setting forth in regulation a detailed definition of severe and disabling chronic condition that might limit plan flexibility.” 70 Fed. Reg. 4596 (Jan. 28, 2005).  Some criticism of the types of C-SNPs approved by CMS.  Sec. 164 of MIPPA provided a definition of severe or disabling chronic condition individuals: “have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care.”  MIPPA also required that the Secretary of Health and Human Services convene a panel of clinical advisors to determine the chronic conditions that meet the definition.

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Key Legal and Regulatory Challenges: C-SNP Issues (Cont’d) – The 2008 Special Needs Plan Chronic Condition Panel identified 15 chronic conditions that meet the definition of severe or disabling. Chronic alcohol and other drug dependence

End-stage liver disease

Certain auto-immune disorders

End-stage renal disease requiring dialysis

Cancer (excluding pre-cancer conditions)

Certain hematologic disorders

Certain cardiovascular disorders

HIV/AIDS

Chronic hear failure

Certain neurologic disorders

Dementia

Stroke

Diabetes mellitus

Chronic lung disorders

Chronic and disabling mental health conditions

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Key Legal and Regulatory Challenges: C-SNP Issues (Cont’d) – Report provided that beginning January 1, 2010, CSNPs can only offer a plan benefit package (PBP) that covers one of the 15 chronic conditions. – CMS may provide some flexibility. The Draft 2010 Call Letter (withdrawn) provided some flexibility to offer multiplecondition C-SNPs. Takeaway: Await additional CMS guidance and consider strategy if currently offer a C-SNP that cannot be renewed in 2010.

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Key Legal and Regulatory Challenges: I-SNP Issues – Must have contract with long-term care facilities. I-SNPs must address certain matters in the long-term care facility contract or provider manual/P&P if the contract specifically refers to the manual or P&P provision.  If a facility chain, must identify each participating facility.  The facility must provide SNP’s clinical staff with appropriate access to the SNP’s members.  SNP must provide care management protocols to facility.  Delineation of services to be provided by SNP and facility.  Training plan so facility staff understand their responsibility under the SNP model of care.

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Key Legal and Regulatory Challenges: I-SNP Issues (Cont’d)  Procedures for facility to maintain a list of credentialed SNP clinical staff in accordance with the facility’s responsibilities under the Medicare Conditions of Participation.  Contract must be for the contract year (through December 31).  Termination clause must clearly state any grounds for early termination. of the contract. The contract must include a clear plan for transitioning the enrollee should the contract terminate See 2008 CMS Call Letter, p. 48-49.

Takeaway: Confirm contracts include all required provisions. CMS will audit for compliance.

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Cut to the Chase!  The future of SNPs is about two things: – “Level playing field” • MA vs. FFS reimbursement • SNPs will have little insulation

– VALUE and ACCOUNTABILITY • SNPs must change the perception that they add no value to Medicare and the health care system • SNPs are “canary in the coalmine” for new regulatory environment

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How Can SNPs Ensure They Are “Special”?

 Meet And Exceed CMS Requirements  Demonstrate Results  Ensure You’re Financially Viable  Get Involved In DC And Tell Your Story

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2008 HEDIS 

CMS contracted with NCQA to evaluate SNPs. The evaluation includes collection of SNP specific HEDIS measures as well as structure and process measures.



SNPs were required to report these HEDIS measures by June 2008: •

Colorectal Cancer Screening*

•

Glaucoma Screening in Older Adults

•

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

•

Pharmacotherapy of COPD Exacerbation**

•

Controlling High Blood Pressure*

•

Persistence of Beta Blocker Treatment After a Heart Attack

•

Osteoporosis Management in Older Women

•

Antidepressant Medication Management

•

Follow-Up After Hospitalization for Mental Illness

•

Annual Monitoring for Patients on Persistent Medications

•

Potentially Harmful Drug-Disease Interactions

•

Use of High Risk Medication in the Elderly

•

Board Certification

* SNP benefit packages under PPO Contracts do not have to report these measures because these measures rely on medical record review. ** This first-year measure is optional for all MA reporting, including the SNP benefit packages. 32

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2008 HEDIS  477 SNPs reviewed  October 6 – NCQA announced it completed evaluation of SNP Structure and Process measures  Evaluation results inconclusive

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HEDIS – 2009 and 2010  2009 – Expect NCQA to provide timeline and requirements in coming weeks – Review 787 SNPs  Expand suite of HEDIS measures, with focus on measures of care for older adults  Integrate CAHPS, HOS  Expand structure and process measures to include care transitions, plan design, caregiver experience  Test benchmark measures

 2010 – Review 787+ SNPs – Refine benchmark measures for collection; expand set of applicable HEDIS measures Source: Source: Presentation Presentation by by Margaret Margaret O O’’Keefe, Keefe, President, President, NCQA NCQA 34 (c) Crowell & Moring LLP 2010. All Rights Reserved.

Meet and Exceed CMS Requirements: Annual NCQA SNP Assessments  Be prepared – these reviews will help determine SNP reauthorization – SNP 1: Complex Case Management  Documented process for identifying members for complex case management  Specific criteria used to identify members eligible for complex case management  Case management procedures  Sample case management reports  Documentation demonstrating how the organization: – Provides program information to eligible members; and – informs and educates practitioners

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Meet and Exceed CMS Requirements: Annual NCQA SNP Assessments 

SNP 2: Improving Member Satisfaction – Documentation demonstrating an evaluation of member

complaint and appeal data – Documentation demonstrating identification of opportunities

for improvement, actions taken, and sharing of results with practitioners and providers



SNP 3: Clinical Quality Improvements – Documentation that demonstrates:  The SNP identified at least three meaningful clinical issues; and  The SNP selected three clinical measures that are relevant to its membership 36 (c) Crowell & Moring LLP 2010. All Rights Reserved.

Demonstrate Results  Care and case management – Measurable improvements in quality of life? – Improvements in quality of care? – Clinical etiology of PMPM cost trends – Integration of medical and drug benefits – Benefit vs. cost of medical management interventions

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Ensure You’re Financially Viable: MA Phasedown to 100% FFS and Impact on Plans  Depends on the period of the phase out  5 year phase out (CHAMP included 3 years)  Gorman estimates: -$17B reduction by 2014 in the national MA benchmark

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What a “Level Playing Field” Means

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What a “Level Playing Field” Means

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What a “Level Playing Field” Means

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What a “Level Playing Field” Means: Rosier Picture in California Due to Efficiencies Aggregate PMPM Impact, Orange County, CA, of a Benchmark Phase Down to 100% of FFS, Weighted by October, 2008 Enrollment. $1,300 $1,200 $1,100 $1,000

4.2 %

3.3 %

$900

4.2 %

4.2 %

4.2 %

$800 $700 $600 2009 FFS, @ 5.5% inflator

2010

2011

2012

Benchmark, current law, @ 5.5% inflator

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2013

2014

Benchmark, phased to 100% FFS

What a “Level Playing Field” Means: Rosier Picture in California Due to Efficiencies

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Geography Matters

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Impact of MA Cuts to Plans  Plan specific impact – depends on the county rate  Many plans will have a reduction in their annual increase over the phase out period  Plans in counties with the highest MA rates compared to Medicare FFS will have a net cut in their rates – Albany with a MA rate of 140% of FFS would have a net reduction each year and -2.1% by 2014  Zero/low-premium plans will have little insulation

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Manage Your Revenue Aggressively  Must be #1 priority for SNPs.  Within next 4 years expect MA $ ~ 100% FFS; can’t leave money on table due to preventable errors  Compliance and finance collide in revenue management – Coding intensity audits on HCCs – Manual requirements on enrollment/PDE reconciliation

 Consider MA Revenue Management function to reduce execution risk and improve performance

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Full Potential of Risk Adjustment Yet to be Realized

1.

Retrospective Chart Review capturing what is in the chart but not in a claim

2.

Substantiation making sure what is in a RAPS submission is supported in the chart

3.

Prospective Evaluation capturing what is “in the member” and making sure it gets into a RAPS The

Potential Yield: Risk-Adjusting Claims Data $1,000-1,600 PMPY

Managing Exposure

ManagingPotential the Patient, the Risk, and Your Yield:Liability via Patient Assessment $3,600 PMPY

Future of HCC Management 47

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Sources of RAPS Submissions

SOURCE

TOTAL YIELD

YIELD/CHART

COST

ROI

AUDIT RISK

Claims

High

Low

Low

High

High

Chart review

High

Moderate

Moderate

High

Moderate

Prospective evaluation

Very high

Very high

High

Very high

Very low

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Prospective Evaluation in Medicare Advantage Programs  Your members must be regularly and completely evaluated by qualified providers who understand Medicare Advantage and risk adjustment  Complete evaluation should be a plan benefit and part of care management – In its January 2008 call letter, CMS said that “any MA eligible population should have health assessments to effectively manage preventive services, diagnostic testing, and therapies.”  The evaluation must incorporate HEDIS measures and published standards of care

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What is the Potential in Prospective Evaluation? When a diabetic with a foot ulcer goes to a podiatrist Dr. Smith 250.00 0.20 707.14 0.484

RAF

Dr. Jones 250.70 0.764 250.60 0.0 443.71 0.0 357.2 0.268 707.14 0.484

0.684

RAF

1.516

Difference in payment between Dr. Smith and Dr. Jones

$

Difference in payment to the plan (PMPY $600 base)

$10,915

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0

Steps in a Prospective Program

 Feedback  Data Collection  Evaluation  Evaluator Selection  Member Selection 51 (c) Crowell & Moring LLP 2010. All Rights Reserved.

The 2008 Coding Intensity Pilot Audit  Launched with five H numbers from five different plans  Blues plan, two major MA plans, large plan with primarily commercial book, provider owned plan  Average contract size ~20,000 members  Audit size 200 members with ~750 HCCs  Exposure of ~$130-150,000 for each code not verified  Pilot expanded to 80 more plans in November 2008  Significant recoveries expected, but not until 2010  Audit results expected to influence 2010 benchmarks 52 (c) Crowell & Moring LLP 2010. All Rights Reserved.

Making Sure What Is In A RAPS Submission Is Supported In The Chart 

About 80% of codes in RAPS come from claims submitted by physicians



But the claim is really a proxy for a chart entry and the assumption is that there will be documentation in a form acceptable to CMS for every code submitted in RAPS  That assumption is true about 70% of the time because of: Missing chart Non-qualified providers Unsigned, undated, or illegible notes Coding errors Typos

Your chart reviews must capture systemic errors in documentation so you can correct them before you are audited. 53 (c) Crowell & Moring LLP 2010. All Rights Reserved.

2007 Part D Reconciliation Results

39%

Receivable from CMS

61%

Payable to CMS

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2007 Part D Reconciliation Results

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Enrollment Drives Your Business Success

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Keys to Success

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Process Evaluation Importance

 Commercial Modeling Mistake  Custom builds are often Pre-Part D Architecture  Red-headed stepchild syndrome  Growing Data/Transaction responsibility  Growth in eligibles will continue to test weaknesses in current “plumbing”

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What is the Future of SNPs?  Expect significant consolidation and attrition among SNPs over next 4 years.  Only strong will survive -- if program is reauthorized. – 2008 NCQA evals inconclusive – 2009 reviews critical to reauthorization.

 C-SNPs will coalesce around handful of conditions.  DE/I-SNPs will be hampered by state Medicaid programs in crisis and disarray.  SNPs could play significant role in Medicare and health reform if they can demonstrate value.

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Questions and Answers

Q&A

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How To Reach Us

Bruce O. Tavel, Esq. Crowell & Moring LLP 1001 Pennsylvania Avenue, NW Washington, DC 20004-2595 Telephone: (202) 624-2961 Facsimile: (202) 628-5661 Email: [email protected] John K. Gorman Chief Executive Officer Gorman Health Group 2176 Wisconsin Avenue, NW Washington, DC 20007 Telephone: (202) 364-8283 Facsimile: (202) 244-8324 Email: [email protected]

61 (c) Crowell & Moring LLP 2010. All Rights Reserved.