Florida based health plan improves risk adjustment score and recaptures lost revenue

A Medicare Advantage Health Plan (MAHP) based in Florida exclusively serves beneficiaries with Medicare, takes pride in its member-centered approach to customer service and the coordination of excellent benefits to meet all health care needs. As of 2021, MAHP serves 8,000+ members across multiple counties including Citrus, Hernando, Hillsborough, Lake, Marion, Pasco, Pinellas and Sumter and has been adding new counties and thousands of new medicare beneficiaries each year.

Challenge

MAHP had been utilizing services of a large technology-enabled services organization (TES) to create and submit Encounter 837 and RAPS file to Palmetto GBA (Palmetto) for medicare beneficiaries enrolled in its multiple Medicare Advantage plan products.

In spite of the engagement running for multiple years, risk adjustment scores assigned by Centers for Medicare and Medicaid Services (CMS) for medicare beneficiaries serviced by MAHP were low compared to its peers.

This impacted MAHP in multiple ways including:

• ■ Bidding at lower than CMS’s benchmark rates
• ■ Low CMS monthly payments and
• ■ Incomplete health profile of medicare beneficiaries

MAHP engaged Mirra to address it’s concerns of low risk adjustment score and lost revenue.

Solution

Once Mirra was engaged by MAHP, team at Mirra formulated a comprehensive plan and a strong governance oversight to ensure the plan was implemented in a timely and compliant manner.

Results

MAHP achieved huge benefits resulting in improved risk adjustment score and recaptured lost revenue.

Comparison of outcomes of CMS’s initial run of 2021 payment year vis-à-vis initial run of 2019 payment year demonstrates the same.

Services

Mirra team employed below services which ensured exceptional results to MAHP.

• Submission services
  ○Creation of Encounter 837 from Provider 837 and Remittance 835 files

  ○Submission of Encounter 837 and RAPS to CMS/Palmetto

  ○Creation of Encounter 837 from Adjudicated claims 837

  ○Analysis of rejections from Palmetto, identification of root cause and corrective actions

  ○Creation of RAPS from Encounter 837

  ○Correction of Encounter and RAPS rejections from Palmetto

  ○Creation of RAPS from Behavioral health/Beacon files

  ○Resubmission of corrected Encounter and RAPS rejections
• Reconciliation services
  ○Identification of gaps in HCC reported between RAPS return files and Encounter 837 submissions

  ○Identification of gaps between Provider 837 and Remittance 835

  ○Identification of gaps between Encounter 837 and MAO-004

  ○Identification of discrepancies between CMS expected vs actual RAF scores for members

  ○Identification of gaps between RAPS return files and MAO-004
• Projection services
  ○Projection of Risk Adjustment Factor (RAF)

  ○Projection of CMS payments
• Services enablers

  Services were performed by in-house personnel experienced in Encounter and RAPS processing and by leveraging technology enabled EDPS, RAPS and HCC products which are:

  ■Developed specifically for Medicare Advantage plans

  ■Hosted in Mirra owned data center in the US

  ■Connected to Palmetto through Palmetto approved Network Service Vendor

  ■Developed leveraging latest technologies and advanced analytics

  ■Kept up-to date with CMS notifications

Reference

Reference of MAHP may be provided to interested parties upon written request.