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.
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.
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.
Key steps included:
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:
- Encounter 837 rejected/disallowed due to multiple reasons, including listed, were not worked uponDuplicate with high risk diag codesInvalid billing provider NPIDates of service not falling within enrollment span of medicare beneficiaryInvalid referring provider NPIService facility location zip code not a valid 9-digit zip codeIneligible CPT code for Professional Encounter 837 with office visit as place of service
- Behavioral Provider 837 were not processed
- Missing 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.
Owing to exceptional work done by Mirra team, risk adjustment scores assigned by CMS to medicare beneficiaries serviced by MAHP increased substantially.
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.
In addition, MAHP recovered:
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.
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 of MAHP may be provided to interested parties upon written request.
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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