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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Health Plans: Choose Your Initial Validation Audit Vendor Wisely


By Anita Nair Hartman/Tuesday, March 21, 2017


For health plans, the time to select an initial validation audit (IVA) vendor is drawing near. Selecting a qualified vendor should be a thoughtful and informed process. If the audit shows a plan’s EDGE data are not valid and have risk score-impacting errors, the Centers for Medicare & Medicaid Services (CMS) may act to scale down the plan’s premium risk transfer payments, which may incur negative results for the plan’s financial performance. As a CMS-accepted IVA entity, we’ve been partnering with health plans to meet this requirement since the law was implemented.

CMS developed IVA requirements to help ensure that accurate and complete membership and risk adjustment information is submitted by health plans to the EDGE servers for eventual payment transfer calculations. According to the regulations, qualified commercial health plans must have an independent auditor with certified coders review medical records for 200 random members (or less if the Finite Population Analysis applies to the issuer) selected by CMS and must validate the enrollment and the diagnosis codes submitted. The deadline to select a vendor for this year is April 28, 2017.

 Medical records review is a critical part of the validation process, so health plans should consider experience and certification when selecting a vendor. Some other important qualities to look for in an IVA vendor are:

●      Deep knowledge of ACA regulations. A vendor should have a history of monitoring, evaluating, and influencing the changing ACA requirements.

●      Data, analytics, and auditing experience. A long history analyzing large claims databases and auditing healthcare claims, and prior experience with CMS-mandated reporting, are critical experiences.

●      Experience with EDGE servers. To efficiently audit EDGE data, the vendor needs experience with EDGE data format and content, and in processing large amounts of data.

●      Risk and reinsurance expertise. Look for an auditor with experience with risk models.

●      Flexible approach. This is not a completely straightforward process. Every health plan is different, and your vendor should be able to implement a solution to meet a health plan’s specific needs.

●      Certified coders. This one is straightforward. By law, the coders must be certified by the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

●      An IVA Approved by CMS. Plans must choose from a list of CMS-accepted entities.

Selecting an experienced and qualified partner to support the IVA will help give health plans peace of mind in managing the IVA requirements. If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, and IVA vendor, so you can get back to the business of offering quality health care. Contact us to learn more.

Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations
Bryan Briegel, Healthcare Reform Solutions Specialist


The EDGE Server Data Submission Requirement Is Alive and Well. How Is Your Process?


By Truven Staff/Wednesday, February 1, 2017



Although the future is always uncertain, there are ongoing, complex reporting requirements we know health plans must meet in 2017. EDGE server data submissions are as challenging as ever, and health plans must submit complete 2016 benefit year data by May 1, 2017. 

Accurate and complete data submissions are a must to ensure that you present the actual risk of your member population and maximize your reinsurance and risk transfer payments. Was your EDGE server software stack upgraded to the new CMS requirements by January 31, 2017 – and are you feeling prepared? We think a few key questions to ask are:

  • How well is our approach to EDGE working?
  • Did we have clean data that optimized our risk adjustment efforts?
  • Were we able to respond effectively to the ongoing changes in CMS requirements? Most recently, how has our CMS-required EDGE server re-imaging and software stack upgrade gone?
  • What improvements do we need to make to maximize our return on our EDGE efforts?

The difficulties in accurately capturing and presenting your members’ risk and effectively processing EDGE data become abundantly clear when health plans receive their annual risk adjustment transfer payment reports from CMS each summer, and many are unhappy. The fact is that many health plans, busy serving their members by supporting quality care at a reasonable cost, simply don’t have the requisite resources or experience in place to complete the arduous tasks needed to comply with EDGE server data submissions. EDGE server requirements are challenging—and continue to evolve.

If you think there’s opportunity for improvement, now’s the time to consider a new direction for your 2017 benefit year submissions. Should you do it on your own? Stick with a vendor you’re not thrilled with? Before you decide, consider all the things that a proper EDGE server process should entail. Your solution should give you:

  • On-time, accurate submissions
  • Ongoing risk optimization services
  • Data management setup and continuous data management services
  • Analytic reporting
  • A support staff to keep up with HHS changes and respond to EDGE server updates
  • Peace of mind and the ability to focus internal resources on your day-to-day responsibilities

What Can Truven Do? Our Data Speaks for Itself.



If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.

 

Bryan Briegel, Healthcare Reform Solutions Specialist 
Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations



EDGE Server Data Submissions: Do You Need Help?


By Bryan Briegel/Thursday, July 7, 2016



Now that health plans have a couple of years of EDGE server data submissions under their belts, it’s a great time to step back and evaluate how your organization did.

We think a few key questions to ask are:

  • How well did our approach to EDGE work?
  • Did we have clean data to optimize our risk adjustment?
  • Were we able to respond to the changes in CMS requirements in a timely and effective manner?
  • What operational improvements do we need to make?

  • The fact is, many health plans — busy serving their members by providing quality care at a reasonable cost — simply don’t have the proper resources or experience in place to complete the arduous tasks needed to comply with the Premium Stabilization Programs. The EDGE server requirements are challenging — and missteps in meeting them have led to disappointing results, including leaving reinsurance dollars and understated risk scores on the table . Even large health plans with corporate supports in place have been challenged to meet the requirements.

If you think there’s a potential for improvement, now is the time to consider a new plan for your EDGE server submissions. Should you continue to go it alone or stick with your current TPA? Before you decide, consider all the things that a proper EDGE server process should entail.

Your solution should give you:

  • On-time, accurate submissions
  • Dynamic data management services, with constant updating to meet CMS changes
  • At a minimum, quarterly analytic reporting
  • Support staff to keep current with CMS changes and respond to their EDGE server inquiries and mandated server updates
  • Peace of mind and the ability to focus internal resources  attending to your day-to-day responsibilities

If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.


Bryan Briegel, Healthcare Reform Solutions Specialist 
Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations



EDGE Server Data Submissions: Do You Need Help?


By Bryan Briegel/Monday, May 18, 2015


 

Now that the April 30 CMS deadline for submitting EDGE server data – and even the May 15th grace period – has passed, it’s a great time to step back and evaluate how your organization did.

We think a few key questions to ask are:

 ·         How well did our approach to EDGE work?

 ·         Did we have clean data to optimize our risk adjustment efforts?

 ·         Were we able to respond to the constant change in CMS requirements in an effective manner?

 ·         What improvements do we need to make?

 The ACA has made an already complicated, competitive business even harder. And the fact is, many health plans — busy serving their members by providing quality care at a reasonable cost — simply don’t have the proper resources or experience in place to complete the arduous tasks needed to comply with the Premium Stabilization Programs. The EDGE server requirements are challenging — and they will continue to evolve. Even large health plans with corporate supports in place were hard-pressed to meet the 2014 requirements.

If you think there’s need for improvement, now’s the time to consider a new plan of attack for your 2015 submissions. Should you do it on your own? Before you decide, consider all the things that a proper EDGE server process should entail. Your solution should give you:

 ·         On-time, accurate submissions

 ·         Ongoing risk score optimization services

 ·         Data management setup and continuous data management services

 ·         At a minimum, quarterly analytic reporting

 ·         A support staff to keep up with HHS changes and respond to their EDGE server inquiries

 ·         Peace of mind and the ability to focus internal resources  attending to your day-to-day responsibilities

If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.

Bryan Briegel, Director of Operations
Anita Nair-Hartman, Vice President, Payer Strategy and Business Operations




Appealing the CMS Risk Adjustment and Reinsurance Calculations: Making Sense of the Discrepancy Regulations


By Bryan Briegel/Friday, April 24, 2015


On March 16, the Centers for Medicare & Medicaid Services (CMS) issued a memorandum to all Edge server issuers, titled Technical Guidance for FORMAL Discrepancy Reporting Procedures Regarding Edge Server Outbound Risk Adjustment and Reinsurance Program Estimate Reports

This technical guidance reminded issuers that if they want to appeal CMS’s risk adjustment and reinsurance calculations, two windows are available to file a formal discrepancy. (A formal discrepancy is a required action to preserve the issuer’s rights to appeal these calculations.)

The first formal discrepancy reporting window allowed issuers to use either the Risk Adjustment & Reinsurance (RARI) reports that CMS triggered in March, 2015, or the RARI reports they triggered on April 3, 2015. This first formal discrepancy reporting window closed on April 14.

The second—and final—formal discrepancy reporting window for issuers who wish to preserve any calculation appeal rights opens on May 4th and closes 15 days later, on May 18th. Because this final formal window is extremely brief and the process is detailed and complex, issuers are naturally looking for a way to gain more time.

The compressed timeline, combined with CMS’s recent decision to trigger RARI reports weekly until April 30, has led to some confusion on which CMS reports may be used to support the second and final formal discrepancy process. Issuers now have so many CMS-triggered RARI reports and so little time that some are planning to use April-triggered reports, but the regulations dictate that the May reports must be used.

Truven Health Analytics encourages issuers to review CMS’s guidance, and ensure they use their May 1–3 CMS-generated RARI reports in any formal discrepancy process. In tandem, we have reached out CMS to ask them to consider publishing an FAQ reminding issuers that only this report may be used in the second and final discrepancy reporting process. To learn more about this issue or other Edge processes, contact us.

Brian Breigel
Director, Operations


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