Government and state sponsored insurance programs such as Medicare Advantage, Individual and Small Group (ACA) and Medicaid are seeing significant growth in enrollment and payers are expanding into these lines of business to diversify their business portfolio. The revenue and reimbursement underlying these types of programs that are received by the payer is based on a complex understanding of how revenue is derived from risk adjustment models both at the Federal level (HHS and CMS) and the State level. There is also an increasing level of oversight form both CMS and the OIG to ensure the payers are being accurately reimbursed for the reported level of illness burden they are responsible for reporting and as a result, health plans face intense scrutiny and must demonstrate a high level of compliance with these programs.
We can help with:
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Operational Program Assessment
- End to end operational assessment
- Current state operations compared to industry best practices
- Areas evaluated:
- Encounter Data Submissions
- Compliance
- Governance
- Analytics & Reporting
- Vendor management
- Prospective programs
- Retrospective programs
- Provider engagement & contracting
- Ingest plan and provider data to identify opportunities for coding improvement
- Prioritization roadmap
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Audit Preparedness
- Review of coding and submission protocols to CMS
- Coding guideline review
- Independent chart review/validation to identify coding vulnerabilities
- Mock RADV
- RADV project support
- Evaluation of financial exposure to OIG or CMS RADV findings
- Review of risk mitigation protocols against best industry best practice
- Adds versus deletes analysis
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Financial & Analytic Reporting
- Financial projections and accruals (mid year and final payment)
- Performance benchmarking
- Data Submission Integrity
- Documentation Improvement Opportunity
- Bid support
- ESRD reconciliation
- Medicare Secondary Payer
- Dual status reconciliation
- Program valuation and ROI analysis
- Bid support
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Clinical Documentation Improvement
- Implementation of clinical documentation best practices
- Implementation of concurrent and/or prospective documentation programs
- Review of coding guidelines and provider education materials
- Creation of KPI’s and performance reporting for CDI programs
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Diligence
- End to end risk adjustment operational due diligence for acquisition target
- Identification of compliance vulnerabilities
- Independent review of medical documentation for HCC validation and opportunities for improvement
- Financial forecasting for risk adjustment reimbursement
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