Curriculum

  • Overview of RA impact across business functions
  • Understand the logic, background, thought process behind RADV & Auditing
  • Learn best practices to ensure compliance and mitigate risk with complete and accurate documentation
  • Calculate your ultimate raw RAF score
  • Map diagnoses to HCC codes; demystifying the Trumping Effect
  • Learn RA strategies to maximize your CMS bid
  • Connect revenue connection between quality and value based payments

This comprehensive 3-hour online course includes highlights from our 8-hour live workshop content  and additional topics

Module 1: Why Do We Have Risk Adjustment? Introduction and History

  • Appreciate the Evolution of Healthcare Acts that have led to Medicare Advantage
  • Identify Program Implementations that changed RA Requirements, Payments and Enrollment Trends

Module 2: What is Risk Adjustment? Core Concepts

  • Realize the purpose of Risk Adjustment in CMS payments
  • Review key components of Medicare Advantage and HHS Risk Adjustment models

Module 3: The "How" of HCCs: From diagnosis to HCC and Back Again

  • Understand hierarchical structure and diagnostic codes for HCC coding
  • Review risk coding v. fee-for-service for reimbursement purposes

Module 4: Now Do The Math: Calculating a Risk Score

  • Calculate the normalization factor and it's impact on risk scores
  • Appreciate using codes accurately for reimbursement

Module 5: The Medicare Two-Model Solution: One Is Not Enough

  • Compare Part C and Part D Risk Adjustment models

Module 6: Plugging Risk Adjustment Into The Annual CMS Bid

  • Understand the steps and roles for bid completion
  • Identify how and when Risk Adjustment influences the bid process

Module 7: The Nuts and Bolts for Revenue Management and Healthplan Compliance

  • Identify RAPS data submission and flow of Risk Adjustment data compared to EDPS data submission flows
  • Identify where to find CMS information regarding the requirements of RAPS

Module 8: The Acid Test: The CMS Risk Adjustment Data Validation Program

  • Review the methodology used by CMS for the RADV including population selection factors, sampling factors, and payment error calculations

Module 9: Applying The Tools: Program Management and Operations

  • Learn how to capture HCC diagnoses annually through prospective and retrospective assessment actions
  • Close gaps and create optimal results with care management, quality and provider engagement

Module 10: Risk Adjustment by Lines of Business

  • Define the differences in Risk Adjustment models: CMS, HHS and Medicaid

Module 11: The Three HHS Models: One Is Not Enough Again

  • Understand the three HHS models and how each is used

Module 12: Win, Lose or Draw: The Zero-Sum Game of HHS Risk Adjustment

  • Learn how the HHS marketplace determines healthplan level liabilities
  • Discover how risk adjustment strategies are critical to financial survival in the HHS marketplace

Module 13: Going Big: Extrapolation in Risk Adjustment Programs

  • Compare extrapolation v. non-extrapolation methods used during an audit

 

Audience

  • Program managers
  • Risk Adjustment Analysts
  • HHS actuaries and analysts
  • Risk Adjustment Operations management
  • Data quality assurance and RADV management
  • HCC coders and auditors
  • Provider educators
  • All levels of management
  • Vendor oversight
  • Clinical risk adjustment management
  • Risk Adjustment and HEDIS Quality Initiatives
  • Advanced analytics

Course Objectives

  • Describe the reasons why risk adjustment was created and the problems it was designed to address
  • Provide a side-by-side comparison of the way risk adjustment tools and program designs work in both the Medicare Advantage and the ACA/HHS marketplace programs
  • Understand how the hierarchical models function, and how they roll up coefficients into RAF scores that ultimately affect risk adjusted premiums
  • Describe the practical differences in the level of diagnostic coding specificity and chart documentation between FFS and government programs (Medicare Advantage and ACA / HHS marketplace)
  • Review performance obligations of payers / issuers under risk adjustment policies, fulfilling duties operationally that include managing an annual calendar schedule
  • Illustrate the strategic use of prospective, retrospective, and concurrent risk adjustment techniques to optimize HCC code capture and documentation
  • Describe best practices in terms of compliance when running a risk adjustment function, including preparation for RADV audits

This program has been approved for 6 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.

This program has the prior approval of AAPC for a maximum of 6.0 continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.  This AAPC approval is valid until 7/31/2021.

Need more help?


Contact Kevin Mowll at kmowll@risehealth.org or 805.845.7673.

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