Speaker Presentation
Thursday, February 22, 2018

Continental Breakfast & Registration


Pre-conference Complimentary Workshop

Intelligent Member Engagement to Manage Risk and Drive Incremental Revenue

In this session you will learn how an intelligent member engagement program utilizing predictive analytics, incentives and personalized communications delivers additional revenue by identifying additional HCCs early while building health affinity with key members. Identifying critical member risks is important to both the member and the Plan. Intelligent incentives direct plan resources at the right members, with the right members and the right message.

Jordan Mauer,EVP Marketing and Member Engagement,NovuHealth


Chairman's Welcome & Opening Remarks

David Meyer,Vice President,SCAN Health Plan


Risk Adjustment Today - New and Proposed Policy Changes & Tech Innovations

This session will address the latest industry policies and the impacts that they are having on risk adjustment processes. Leveraging the knowledge today to enhance processes for tomorrow. Focus will be on:

  • New and proposed policies impacting risk adjustment
  • Emerging technology and services to enhance interventions
  • Latest topics and trends facing the healthcare industry

Jessica Smith,Vice President, Analytics & Compliance,Gorman Health Group, LLC


Improving Quality of Business Processes to Augment Risk Adjustment and Revenue Management

Kristina Trafton,Director-Risk Adjustment, Risk and Revenue Management,Geisinger Health Plan


Networking Refreshment Break


RAPS vs. EDPS -- The Changing Environment & Financial Impact of Reporting Risk Adjustment & How to Reconcile at the HCC Level

Medicare Advantage is dependent on the non-traditional hierarchical condition categories (HCC) payment system through data captured simultaneously in two separate reporting systems. These systems include the risk adjustment payment system (RAPS) and the encounter data processing systems (EDPS). The intent is that at a future date, CMS will have EDPS completely replace RAPS and the CY2016 payment began this progression that will ultimately support an expected 90/10 split payment for 2015 DOS. In this session we will dive into the differences of the systems, give a case study of how one health plan was able to reconcile and manage the evolution through 2017, and provide you with an approach that may impact the way your teams collaborate to address this change in the risk adjustment reporting process.

  • Examine the different approaches available to address risk adjustment accuracy
  • Outline the key differences between the RAPS and EDPS reporting systems
  • Dive into one plan's lessons learned with reconciling RAPS vs. EDPS data
  • Review and discuss CMS best practices in approaching HCC reconciliation
  • The ability to use our techniques for your plan's data to identify discrepancies between the reporting systems

Dawn Peterson,Director of Utilization Management and Risk Adjustment Solutions,Health Alliance


Networking Lunch


Integrating Risk Adjustment into Alternative Payment Models (APM): An Enterprise Approach

As Federal policy trims margin on financial payments to control cost, the Physician group and Hospital landscape continues to evolve making shared risk among payers a vital part of Network contracting. How will your risk adjustment program integrate with internal and external stakeholders to maintain and improve risk scores while accommodating new payment structures in the market? This session will focus on the following key objectives to drive program integrity while adapting to new payment methodologies:

  • APM Governance and a seat at the table
  • Network Contracts - the tie that binds
  • Enterprise Alignment and program migration
  • Incorporating risk adjustment into the APMs
  • Leveraging APMs to drive technology and program results

Jennifer Zucchero,Manager, Risk Revenue,Gateway Health Plan


Real Provider Engagement - [The key to all of your outcome dreams]

There are no shortcuts to achieving alignment with your providers community and government program rules. High touch, education-centric, technology and process agnostic provider engagement programs with win win incentive models are the key to achieving your desired government program results.

  1. Technology agnostic approaches to meet providers where they are
  2. How to define the right incentive model to achieve desired outcomes
  3. Concurrent review strategies to both educate and create alignment

Sue Kuypers, Managing Director, Product Management,Tessellate


Networking Refreshment Break


Integrating HEDIS & Risk Adjustment Efforts to Optimize Patient Outcomes

Integrating HEDIS and risk adjustment efforts can increase efficiency through more effective use of resources, and lead to optimization of patient outcomes and accurate scores.

Topics to be covered in this talk include:

  • Setting priorities, identifying opportunities and defining goals;
  • Maximizing time with the patient;
  • Provider education and engagement;
  • Cross-functional data sharing and examples of how to implement processes based upon this data;
  • The role of retrospective chart reviews and prospective assessments;
  • Best coding and billing practices to ensure the most accurate risk and HEDIS scores.

Tara A. Russo,VP of Medicare Risk Adjustment and HEDIS Quality Initiatives, VP of Navigate Directorate,Island Doctors


Part I: RADV Proactive Compliance

* Review RADV audit trends and assess factors that may elicit audit selection

  • Understand the intersection of compliance and risk adjustment in RADV preparedness and response mechanisms
  • Outline tactics and strategies to mitigate audit risk while optimizing risk-adjusted revenue
  • Navigate outsourcing and oversight of vendor partnerships
  • Assess financial and operational infrastructure and determine whether to build capabilities or outsource
  • Consider incorporating RADV into existing vendor partnerships and outsourcing
  • Discuss how to maximize the effectiveness of and return for RADV outsourcing
  • Discuss lessons learned and best practices that can be applied to the 2017 RADV cycle

Mital Panara,Vice President, Revenue Management,Freedom Health, Optimum Health


Part II RADV: Best Practices for a Successful RADV -- Operations & Project Management

David Meyer,Vice President,SCAN Health Plan


Networking Reception

Friday, February 23, 2018

Continental Breakfast


Chairperson's Remarks

David Meyer,Vice President,SCAN Health Plan


Implementing Risk Adjustment in Shared Savings Arrangements with Providers

In this session, CDPHP will discuss the challenges encountered in the development of a sound risk adjustment mechanism for its shared savings arrangements with providers. Additionally, CDPHP will also discuss methodology for risk adjustment model evaluation, share provider concerns and touch upon some aspects of implementation.

Puneet Budhiraja ASA MAAA,Medicare / Chief Actuary,Capital District Physicians' Health Plan, Inc. (CDPHP)


Relevant Prospective and Retrospective Analytics to Drive Action

Gaurishankar Chandrashekhar, Director of Revenue Management, Finance Department,Harvard Pilgrim Health Care


Networking Refreshment Break


Gaps in Care Closures - Reducing Member Non-Compliance

The key to increasing both HEDIS/Stars Measures requires reducing member non-compliance. The ABC's of closing the gaps includes a current/real-time easily accessible Gaps In Care Report. Learn how one regional HMO uses a 4-Point member-centric approach to aid in closing Gaps In Care at every point of contact with the member which includes:

  • All Call Centers
  • Walk- in Service Centers
  • Case/Care Managers
  • Providers

Linda Lee,Vice President, Quality Improvement,MCS Healthcare Holdings LLC


What You Need to Know About Recent Risk Adjustment Fraud Litigation

Risk adjustment fraud litigation has exploded in the last several years. Department of Justice lawyers and whistleblowers are bringing False Claims Act and other lawsuits that are reshaping the face of risk adjustment, attacking Medicare Advantage Organizations' and other entities' filter logic, chart review processes, RAPS submissions, fraud detection and compliance efforts, and multiple other aspects of their processes. This session will include a discussion of the pending government's False Claims Act cases against UnitedHealth and UnitedHealth's related suit against the Department of Health and Human Services challenging its overpayment refund rules, among other pending and recent risk adjustment fraud lawsuits, as well as takeaways and lessons learned from such litigation.

Michael Matthews,Partner,Foley & Lardner LLP


Close of Conference