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

13th, Mar 2023

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

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.

Solution
Key steps included:
Baselining of current scores
Identification of root causes for low scores
Identification of solutions to root causes
Implementation of solutions and
Documentation and reporting of improved scores

Institutional, Professional, Durable Medical Equipment and Behavioral Provider 837, Remittance 835, Adjudicated claims 837, Encounter 837, RAPS return files, 999, 277, MAO-001, MAO-002, MAO-004, MMR and MODR generated as part of services provided by TES were analyzed and root causes identified for low scores.

Root causes included:
  • Root causes includedEncounter 837 rejected/disallowed due to multiple reasons, including listed, were not worked upon
     Duplicate with high risk diag codesDuplicate with high risk diag codes
     Invalid billing provider NPIInvalid billing provider NPI
    Dates of service not falling within enrollment span of medicare beneficiaryDates of service not falling within enrollment span of medicare beneficiary
     Invalid referring provider NPIInvalid referring provider NPI
    Service facility location zip code not a valid 9-digit zip codeService facility location zip code not a valid 9-digit zip code
    Ineligible CPT code for Professional Encounter 837 with office visit as place of serviceIneligible CPT code for Professional Encounter 837 with office visit as place of service
  • Behavioral Provider 837 were not processedBehavioral Provider 837 were not processed
  • Missing Encounter 837 and RAPS filesMissing Encounter 837 and RAPS files

Mirra team formulated solutions for reach of the identified root causes, implemented them in a timely and compliant manner while ensuring highest quality.

Solutions included:
Analysis of rejected/disallowed Encounter 837, creation of Chart reviews and/or corrected Encounter 837, submission to Palmetto and tracking until they are accepted
Reconciliation between Payment 835 and Encounter 837, identification of missing Encounter 837, creation of missing Encounter 837, submission to Palmetto and tracking until they are accepted
Creation of Encounter 837 and RAPS return files from Behavioral Provider 837, submission to Palmetto and tracking until they are accepted
Reconciliation between RAPS files and Encounter 837, identification of missing RAPS files, creation of missing RAPS files, submission to Palmetto and tracking until they are accepted

Owing to exceptional work done by Mirra team, risk adjustment scores assigned by CMS to medicare beneficiaries serviced by MAHP increased substantially.

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.

Risk adjustment scores at plan level of 1.32 vis-à-vis 1.08, an increase of 22%
HCCs submitted of 45,294 vis-à-vis 25,811, an increase of 75%
HCCs submitted of 5.3/member vis-à-vis 3.39/member, an increase of 56%
Monthly CMS payment of $8.1 million vis-à-vis $5.1 million, an increase of 58%
Per member per month CMS payment of $948 vis-à-vis $682, an increase of 39%
In addition, MAHP recovered:
$2.8 million, $128 per member per month, of CMS payment during final run of 2019 payment year
$1.1 million, $145 per member per month, of CMS payment during mid-year run of 2020 payment year

TES was providing submission and reconciliation services to MAHP during CMS’s initial run of 2019 payment year while Mirra provided submission, reconciliation and projection services to MAHP during CMS’s initial run of 2021 payment year.

Services

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

  • case-noteSubmission 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
  • case-refreshReconciliation 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
  • case-circleProjection services
    Projection of Risk Adjustment Factor (RAF)
    Projection of CMS payments
  • service-enableServices 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.

Reviews & Testimonials

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"In 2021, Ultimate Health Plans (UHP) partnered with Mirra Health Care (Mirra) to develop a software platform to support processing Claims, Customer Service, Eligibility, Enrollment, Premium Billing, Encounter Processing and a Provider Portal for our Medicare Advantage Plans.

Mirra collaborated well with our operations and compliance teams to successfully design and implement a system that was innovative, efficient, and compliant with all Medicare and Florida Medicaid guidelines and requirements all within the scope of our required timeline.

We greatly benefitted from the Mirra Project Management Team’s regular communication with Stakeholders through monthly meetings and recurring weekly breakout-focused calls, which were geared towards troubleshooting and goal alignment. Mirra was able to quickly maneuver and adapt their systems to our needs, resulting in successful implementation and go-live. Mirra continues to support our compliant operation and growth in the ever-changing healthcare industry rapidly and effectively updating their systems with new Medicare and Florida Medicaid rates and guidelines to ensure seamless compliance and efficiency. I have absolutely no reservation in recommending their systems to any Payer searching for improvement in their operational efficiency."

NANCY GAREAUCEO of Ultimate Health Plans

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