Medicare Diagnosis Code Closure

November 15, 2013

IMPORTANT INFORMATION

Correct Coding…More Shopping

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Medicare Advantage Gain Sharing

Blue Cross Blue Shield of Michigan and Blue Care Network

are partnering with providers to improve performance for

Blues Medicare Advantage products related to:

Documentation and coding for appropriate risk adjustment

Utilization and cost management

Performance on quality measures (Center for Medicare &

Medicaid Services STARS)

The Blues are doing this through a new Blues Medicare Advantage Gain Sharing program.

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Medicare Advantage Gain Sharing

What is Medicare Advantage Gain Sharing? New provider incentive program offered by Blue Cross

Blue Shield of Michigan and Blue Care Network Focuses on BCBSM’s Medicare Plus Blue PPOSM and

BCN Advantage HMO-POSSM Rewards providers by giving them a share of the

financial “gain” associated with provider performance improvement

Provides support to enable providers to be successful Select medical care groups invited to participate in

first phase (Fall 2012 through December 2013)

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Gain Sharing Model: Step One

Blues Total Premium Revenue

89% Medical Expense Fund (underwritten members)

11% Blues Plan Administration*

*Blues Plan Administration includes:• BCN Advantage payment of $1.50 pmpmto medical care groups• Medicare Advantage PPO reimbursement for provider-directed case management

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Gain Sharing Model: Step Two

Medical Expenses

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Medical Expense Fund

• All Medical Expenses • Carve Outs (Rx, behavioral health –

both, lab/DME/dialysis – BCN only)

• BCN Advantage Reinsurance

Gain or Loss

Gain – Providers share gains Loss – Blues cover all losses

The group must achieve an 89% or lower medical loss ratio to participate in the program.

Gain Sharing Model: Step Three

Gain Sharing

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• Physicians covering 80% of the BCN Advantage/Medicare Plus Blue PPO membership

• 1 office/billing manager per office covering 80% of membership

Education Criteria (25%)

• Accurate coding/closing diagnosis code gaps

• Improvement in quality score

• Improvement in readmission rate

Performance Criteria (10%)

• Must achieve both Education Criteria to meet Education Incentive

• Must achieve Education Incentive to qualify for the Performance Incentive

• All three of the Performance Criteria must be met to achieve the Performance Incentive

Total Possible (35%)

+

=

Education Criteria

Education (25 percent of gain) – To achieve, must complete BOTH 1 and 2. 1. Primary care physicians who cover at least 80 percent of the Medicare Plus

Blue PPO and BCN Advantage membership attend a Medicare educational

session on:

• The gain sharing model and other physician incentives

• Risk adjustment, coding and documentation

• STARS measures

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Education Criteria

2. Office staff from offices that cover at least 80 percent of

the Medicare Plus Blue PPO and BCN Advantage

membership attend a similar Medicare educational

session.

• At least one staff person per office (preferably billing manager or office manager) will receive appropriate training.

• May be in-person training, webinar, office visit, etc.

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‾ You must achieve the Education Incentive to qualify for the Performance Incentive

‾ If you do not achieve the Education Incentive there is no gain sharing.

Performance Criteria

Performance (10 percent of gain) – To achieve, must complete all three

performance criteria.

All are scored at the medical care group level.

1. Accurate coding/closing diagnosis code gaps: • Appropriate diagnoses have been captured for 90 percent of the members

identified or information has been provided that diagnoses expected were not valid.

– BCN Advantage/Medicare Plus Blue PPO will provide information on expected diagnoses for all members on Health e-Blue web. Reports provided through September 2013 comprise the target population.

– A face-to-face visit is required to close a gap

– All gaps must be closed following CDC and CMS standards

− Gaps closed by Inovalon (vendor) will not count for provider

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Performance Criteria

2. Improvement in quality score: • Based on 2012 Composite Quality Score from the Health e-Blue Quality

Summary Report. Improvements must occur before end of 2013.

• Measured separately for both Medicare Plus Blue PPO and BCN Advantage. Must achieve minimum improvement for each.

• Improvement measured on sliding scale. Lower scores require more improvement.

• Measured at the medical care group level – not at individual physician level.

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Performance Criteria

3. Improvement in readmission rate:

• Based on 2012 rate. Improvements must occur before end of 2013.

• Measured for combined population (Medicare Plus Blue PPO and BCN Advantage)

• Measured at the medical care group level – not at individual physician level.

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What If…

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What if one of the following happens? • The group does not meet the 89% medical loss ratio • The group does not meet the Education Criteria

Then the group does not qualify for any Gain Sharing and cannot participate in the Gain Sharing Performance Criteria. Primary care physicians from a group that does not qualify for Gain Sharing are eligible to participate in the Blues’ Medicare Advantage Diagnosis Closure Incentive program.

Diagnosis Closure Incentive

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Providers cannot participate in both the Gain Sharing Performance Criteria and the Diagnosis Closure Incentive program. Only one of these incentives can be earned. Diagnosis Closure Incentive highlights: • Measured at the individual physician level • PCPs with one or more Blues Medicare Advantage patients with at least one

open diagnosis gap identified by the Blues will receive $100 for closing 100% of the patient’s diagnosis code gaps

• Suspected or historic conditions not accurately documented and coded in the current year are diagnosis gaps

• Diagnosis gaps will be identified in the new Diagnosis Evaluation report on Health e-Blue (available by March 2013 and refreshed monthly).

• Gaps identified by the Blues January 1 through September 30, 2013 are eligible for payment.

Diagnosis Closure Incentive

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To earn payment for a patient: • All the patient’s gaps must be closed in 2013 and reported

to the Blues by January 31, 2014 • The gaps must be closed following a face-to-face visit • The diagnosed conditions must be addressed at the face-

to-face visit • Coding and documentation must follow CDC and CMS

standards

Gaps closed by Inovalon (vendor) will not count for the provider

What If…

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What if our group could have earned more money in the Diagnosis Closure Incentive? • The Blues will calculate the group’s incentive for the Gain

Sharing 10% Performance Criteria and compare it to the aggregate PCP payment that could have been earned through the Diagnosis Closure Incentive.

• The Blues will pay the larger of the above two incentives.

What If: Example One

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Medical Care Group

Blues Medicare Advantage Value Incentive Program Gain Sharing Example (CY 2013)

Additional Criteria MCG Must Meet Prior to release of any earned surplus for which MCG is eligible

Total Gain (Revenue Less Expense) $200,000 MCG Potential Share of Gain

- Base Financial Gain Incentive (25%) $50,000 Physician and Office Staff Training re: Coding, STARS, etc. (Both criteria must be met)

- Supplemental Financial Gain Incentive (10%) (1)

$20,000 Close Dx Code Gaps, Improvement in Quality Scores, Improvement in Readmission Rate (All three criteria must be met.)

Potential Gain Available to MCG (2) $70,000

1. See alternative incentive below. 2. Does not account for any CMS limitation on gain.

Diagnosis Code Gap Closure Incentive Compared to Supplemental Financial Gain

Assume: - MD gets $100 for each Dx Gap closed. $100

- 300 members’ Dx gaps closed by MCG physicians

300

- Total Dx Gap Closed Incentive Value $30,000

Supplemental (10%) Financial Gain Earned by MCG

$20,000 Since the total value of the Closed Dx gaps (i.e. $30,000) is greater than the Supplemental Financial Gain (i.e. $20,000), BCN will distribute the $30,000 directly to and among the individual MCG PCPs who closed the gaps. The $20,000 earned by MCG will not be paid.

What If… Example Two

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ICD-9 Description HCC Revenue ICD-9 Description HCC Revenue

250 Diabetes 19 $1,307 250.60

Diabetes w/

neurological

manifestations

16 $3,291

Polyneuropathy 17 $2,637

Total Monthly Premium Revenue to Health Plan $1,307 Total Monthly Premium Revenue to Health Plan $5,928

Amount Allocated to the MCG Medical Services Fund

(@ 89%) (1) $1,163

Amount Allocated to the MCG BCBSM Medicare

Plus Blue PPO Medical Services Fund (@89%) $5,276

Net Annual Medical Funding to MCG for this BCBSM

Medicare Plus Blue PPO member $13, 956

Net Annual Medical Funding to MCG for this

BCBSM Medicare Plus Blue PPO member $63,312

Assume: Annual Expenses for this member $20,000 Assume: Annual Expenses for this member $20,000

MCG Medical Service Fund Gain (Loss) for treating

this member. ($6,040)

MCG Medical Service Fund Gain (Loss) for

treating this member $43,312

MCG Share of Gain (up to 35% if criteria is met) N/A (2) MCG Share of Gain (up to 35% if criteria is met) $15, 159

(1) Same example above applies for BCN Medicare Advantage Value Incentive Program, except for certain services (and allocated premium) that are “carved-out” and for which MCG is not responsible (e.g. DME, Lab, Behavioral Health, Outpatient Lab)

(2) MCG is not a financial risk for any losses in this program. BCBSM assumes financial risk for all losses.