The Centers for Medicare and Medicaid Services (CMS) publish star ratings to measure the quality of Medicare Advantage and Medicare Part D plans. They are also published to help beneficiaries select the best plans for them and to financially reward high-quality plans.
In this article, Milliman’s Dustin Grzeskowiak and Pat Zenner provide an overview of CMS’s methodology for calculating star ratings. Additionally, the authors discuss the financial and marketing implications of star ratings for Medicare plans and summarize best practices common to high-rated plans.
The purpose of engaging providers in the ICD-10 transition is to create stellar physician documentation and coding, which could make ICD-10 coding beneficial to providers and patients—accurate and complete patient records can be used to facilitate care consistency and coordination, promoting evidence-based practice and appropriate reimbursement for services rendered.
Recent surveys have found, however, that most providers are not yet engaged in the ICD-10 transition. Organizations must plan and implement focused efforts to change superior documentation and coding from lofty goals to practical ones.
In this paper, we discuss the emerging best practices to engage physicians in the ICD-10 transition.
The immediate focus of most HIPAA organizations and their vendors is on the conversion and mitigation of potential risks related to ICD-10 implementation. Many of those risks relate to the data fog that will ensue for at least 18 months following the October 1, 2013, implementation.
Some organizations have thought about what will happen after the data fog clears—the long-term advantages that ICD-10 will likely offer include better identification of fraud or abusive practices, improved ability to manage care and disease processes, and tracking public health and risks.
However, few have thought about the immediate opportunities that ICD-10 offers starting on the first day of implementation. Organizations do not have to wait two or more years for historical ICD-10 data to improve condition management, enhance population management, or engage in outcomes analysis. With a little foresight, organizations may even be able to use ICD-10 to improve coding. Find out more in this new white paper.
We’ve blogged before about ICD-10, the clinical coding set that all U.S. payors have to convert to by Oct. 1, 2013. Managed Healthcare Executive covers the slow move among some health plans toward ICD-10 preparedness. Here’s an excerpt:
“As much as individuals and organizations in the industry have tried to raise awareness of ICD-10, we still have organizations come to us and say they’re are not getting the attention of senior management,” says Patricia A. Zenner, healthcare management consultant with actuarial firm Milliman, Inc.
In fact, a survey of MANAGED HEALTHCARE EXECUTIVE readers published in October 2010 indicated that 33% of payers and 45% of providers had not taken any action on ICD-10 implementation. While it’s in the best interest of providers to complete the transition early, just 4% of those surveyed indicated they were nearing completion of the conversion.
Payers will have a secondary concern when the Oct. 1, 2013, conversion deadline nears, because they’ll undoubtedly receive claims in ICD-9 and ICD-10 during a prolonged transitionary period. In other words, they’ll need to have two systems operating simultaneously to handle both types of transactions. According to the MHE research, about 6% of payers were nearing completion of their conversion last October.
For more details read the full article.
We’ve blogged before about prevention and the difficulty of determining returns on preventive care investments. Now comes a new wrinkle: The inner details of the reform law. Atlantic Information Systems looks at prevention and health reform in a new article, “Health Reform’s Prevention-Services Rule Perplexes Health Plans With Coverage Mandates Open to Questions.” Here is an excerpt (and perspective from senior clinicial consultant Patricia Zenner):
Zenner cites numerous examples of practical challenges for plans trying to administer the new preventive-coverage mandates. Among them:
There are broad CPT codes for laboratory studies, such as an analytical technique called mass spectrometry, “that could test for absolutely anything,” Zenner says, “and there is no way to differentiate it on the claim. That could make it difficult for a plan to show it is providing the required specific screenings for newborns, she says.
The rule’s call for mammography screenings every one to two years for women over age 40 still presents a challenge despite coding differences for preventive mammograms and diagnostic mammograms. That is because “something might start out as a screening test and ultimately become a diagnostic test, and the billing process becomes complex,” she explains.
The rule calls for Rh factor incompatibility screening for all pregnant women and follow-up testing for women at higher risk. According to practice guidelines, such testing should be done at 24 weeks’ to 28 weeks’ gestation unless the father’s blood type is known to be Rh negative, Zenner says. “But how would you know the father’s status?” she asks. “In this case, I think health plans will just have to pay” for the screening at the first pregnancy visit and again at 24 weeks’ to 28 weeks’ gestation.
Various other complications are outlined in the full article.
A new article on the blog ICD-10 Watch looks at the risks associated with ICD-10 implementations, quoting ICD-10 expert Patricia Zenner. Here is an excerpt explaining four key risks:
In this phase, Zenner recommends that organizations identify goals, allocate resources to making necessary changes, chart a road map for how to achieve ICD-10 compliance and communicate with external partners.
“Analyze and test the portion of codes not cleanly mapped in order to assess the potential reimbursement impact, modify standardized schemes, modify contracts to provide for the uncertainty that will accompany the transition ‘data fog,’” Zenner writes.
What with the clock ticking, the implementation phase is the time to actually provide those allocated resources so your organization can achieve timely and accurate coding and reimbursement, Zenner adds. “Be over-prepared to address issues as they arise.”
Once ICD-10 is implemented and compliance day, October 1, 2013 has come and gone, healthcare organizations will need to monitor KPIs (key performance indicators) for any potential issues, actively manage reimbursement, and continue to promote open communication, Zenner explains.
For more on ICD-10, see these other resources: