Your First Look at Payments for 2007

Today, December 22, CMS will deliver your Monthly Membership Report (MMR) for January. What makes this MMR of special interest? It’s your first look at member payments under 100% risk adjustment (last year, payments still included a demographic component of 25 percent). If your plan has been doing a good job of HCC-based risk management over the past 12 months, then your MMR for January 2007 should contain few surprises. Congratulations!

Not so happy with your January MMR results? Then it’s time to take a closer look at ensuring your members are completely and accurately coded for risk, both retrospectively for 2006 dates of service, and prospectively for 2007. Plans which are not actively focused on the risk profile of their membership during 2007 face an uphill battle against the rising cost of care. Moreover, plans which do nothing will see their risk adjustment scores (and payments) decline.

Current Leprechaun clients are seeing incremental revenue increases between $40 and $80 PMPM as a result of Leprechaun’s expertise in managing HCC-based risk adjustment for Medicare Advantage plans.

Medicare Clarifies Data Submission Requirements

On December 6th, Medicare announced two important clarifications regarding data submissions to RAPS:

1. Submission of risk adjustment production files must submit at least once every calendar quarter; and
2. Reduction of duplicate risk adjustment submissions must adhere to no more than five percent (5%) per file. We define a duplicate submission as a diagnosis cluster with the same attributes as that already stored in the RAPS database; duplicate submissions result in 502 errors.

We've seen plans that don't stay current with their RAPS submissions, and it's an operational red flag. The 5% allowance for 502 errors means that you have to know what you have already submitted. Again, CMS is forcing plans to clean up their data processing act.

If call this is Greek to your ears, please give me a call (1-888-LEPMED1, ask for Mike Duffy), and I'll be happy to clarify what it means. Existing Leprechaun clients should know that we are aware of these changes and will comply.

Bart Starr is Old Enough for Medicare

In fact, he's not only a Medicare Advantage plan member, but UnitedHealth Group has selected Bart and Cherry Starr as spokespersons for their MA plan.

Obviously, announcements like these show that plans are in the heat of enrollment season, and draw attention to the recent press release (PDF) from the Centers for Medicare and Medicaid stating

CMS has received complaints concerning inappropriate marketing activities performed by sales agents...CMS is closely monitoring and tracking complaints related to the activities of sales agents and has begun taking corrective actions as necessary.

It's a shame that this sort thing happens in the name of taking care of older Americans. Please make sure that your plan is doing the right thing.

Thanks to Gorman Health Group's excellent newsletter (free!) for the information on CMS.