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Speaker Presentation
Module #1
Wednesday, September 23, 2020: 10 a.m. – 12:30 p.m. ET
Regulations, Policy, Audit -- Ensuring Compliance

Welcome & Introduction


Dawn Peterson,Director of Risk Adjustment,Martin’s Point Health Care


How to Improve Point-of-Care Outcomes: Advancing Risk Capture Beyond Charts & IHAs

MA and ACA health plans continue to spend millions on the traditional risk documentation capture activities of chart reviews and in-home assessments because of their struggles to improve point-of-care documentation. Join Jeff De Los Reyes and Brandon Solomon as they present on pragmatic, market-proven, approaches to improving point-of-care risk documentation outcomes.

  • Insights into how other health plans are approaching their prospective risk campaign strategies (both the good and the bad)
  • Analytic and technology considerations for strengthening current programs
  • Recommendations that can be applied to improve short and long-term performance outcomes

Jeff De Los Reyes,Senior Vice President, Healthcare Analytics and Risk Adjustment Solutions,Gorman Health Group

Brandon Soloman, Vice President, Client Advisory & Business Development,Pareto Intelligence


Advocacy & Legislation for Risk Adjustment Flexibility Now and Post-Pandemic

This session will provide a high level legislative and regulatory update that will encompass 2020 proposed and finalized changes impacting our industry in 2021 and beyond. We will review the COVID-19 regulatory flexibilities granted to plans for the duration of the pandemic specifically those related to the MA risk adjustment program. Then we will cover the current outstanding issues that have not yet been addressed that will impact the future of the MA risk adjustment program as a result of COVID-19.

Aldiana Krizanovic,Senior Health Policy Consultant, Federal Government Relations,Florida Blue


Panel Discussion: Impact of COVID-19 – Strategies to Drive Revenue for 2021


Dr. Adele Towers,Director of Risk Adjustment,UPMC Enterprises


Jimmy Liu,Vice President, Risk Analytics,Change Healthcare

Dawn Peterson,Director of Risk Adjustment,Martin’s Point Health Care


Auditing for RADV Compliance – New Procedures Post Pandemic

Erika Bergstresser,Director of Risk Analytics,Gateway Health Plan

Module #2
Wednesday, September 23, 2020: 2-4:30 p.m. ET

Opening Remarks


Jen Hayes,Manager of Quality, HEDIS & Coding,Highmark


Moving Toward Provider Risk Sharing Arrangements – Impact on Risk Adjustment

  • As the healthcare industry evolves toward improving quality outcomes through innovative funding arrangements, Medicare markets have begun exploring the spectrum of risk-sharing arrangements between providers and health plans.
  • Understand provider considerations in accepting risk contracts
  • Understanding risk coding dynamics in risk based contracts
  • Impact on of COVID19 on health care system and the opportunity with Value Based Contracts

Puneet Budhiraja,Senior Vice President, Chief Actuary,Capital District Physicians’ Health Plan


As the EDPS Phase In Continues, Are You Prepared for the Transition?

The wait is over! CMS has been gradually phasing in EDPS for use in Medicare Advantage payment blending and 2021 will be the first year that EDPS is weighted more than RAPS for calculating risk adjusted payments to Medicare Advantage Organizations (MAOs). This session will discuss the differences between the two CMS systems, impacts to MAOs and strategies to mitigate the risk as we move toward full transition.

Tim Plank Director, Government Revenue Risk Adjustment, Insurance Services Division UPMC Health Plan

New Frontiers: Telehealth, AI & NLP Innovations for Risk Revenue

Telehealth Strategy to Maximize Program Effectiveness & Prevent Additional Coding Gaps

  • Assess the model that best fits your business needs: provider, vendor, combination
  • Target members for telehealth assessments
  • Maximize Engagement/Conversion Rates

Gaurishankar Chandrashekhar,Director of Revenue Management,Harvard Pilgrim HealthCare


Utilizing Telehealth to Optimize Risk Revenue

In light of the COVID-19 pandemic, health plans are challenged to ensure validation of member risk to preserve risk revenue targets.  Waiver 1135 issued by CMS lifted restrictions for telehealth services, but not all telehealth is created equal.  This session will focus on the key strategies required to utilize telehealth appropriately for risk adjustment.

  • Discuss CMS changes and visit requirements for Telehealth visits
  • Review Risk Adjustment visit and documentation requirements
  • Examine Risk Adjustment coding for COVID-19

Jen Hayes,Manager of Quality, HEDIS & Coding,Highmark


Optimizing Provider Engagement with a Point of Care Tool and NLP Claims Analysis

UPMC has implemented a point of care and claims analysis tool since 2018 for Medicare Advantage, ACA, and Medicaid lines of business. Initial pilot results were favorable and widespread implementation began July 9, 2019. In the year since utilization, claims accuracy has improved and providers are assisted with appropriate documentation and capture of HCC codes. Financial outcomes will be presented.

Dr. Adele Towers,Director of Risk Adjustment,UPMC Enterprises


Digital Transformation, Technology Impact on Risk and Quality Programs

Health care is quickly transforming to digital, accelerating access to clinical data. Using NLP technology coupled with AI and machine learning will take Risk adjustment and Quality programs into a new phase that will enhance the following:

  • Detection: Ability to detect condition based coding patterns
  • Prognosis: Ability to detect new condition early based on leading heath indicators
  • Visibility: Provide additional visibility based on clinical documentation patterns
Looking to the future, NLP will have proven to change how we define and work with Risk adjustment programs. During this session, Andy will review how the technology can transform risk programs, HCC Coding benefits, compliance, and the anticipated positive financial impact to Health Plans.

Andy Kumar, VP Product Management & Strategy,Ciox Health


Close of Module # 2

Module #3
Thursday, September 24, 2020: 10 – 12:30 p.m. ET

Opening Remarks


Dawn Peterson,Director of Risk Adjustment,Martin’s Point Health Care


Panel Discussion: Vendor Management and How Technology Can Increase Accuracy, Quality & Compliance


Dan Weaver,Vice President, Stars, Quality & Risk Adjustment,Gateway Health


Antonette Buenavides,Dir. Risk Adjustment Programs & Audit,SCAN Health Plan

Zoe Lutes, Director of Utilization Management & Risk Adjustment,Health Alliance

Brandon Soloman,Vice President, Client Advisory & Business Development,Pareto Intelligence


CASE STUDY: Augmenting Coding with AI and NLP to Exponentially Increase Efficiency & Minimize Outsourcing

Hear from Network Health on their experience using Natural Language Processing (NLP) for second pass chart reviews to drive complete and accurate coding and improve revenue.  Network Health continues to push the use of technology for chart retrieval and medical record review to increase efficiencies, reduce costs, improve ROI and minimize outsourcing.  The presentation will discuss both successes and challenges with implementing new technologies to support revenue and quality initiatives, including Network's experience with its clinically integrated provider partners.  Available technologies being discussed include NLP, clinical data extraction (CDE) as a service, electronic data interchange (EDI) tools, embedded coder workflow solutions and payer/provider interoperability tools.

Josh Weisbrod, Vice President, Risk Adjustment,Network Health

Provider Collaborations for Data Capture and Coding

Enable Providers to Self-Audit Submitted Claims for Missing Risk Adjustment Conditions

Risk adjustment activities are needed because providers often do not capture or submit all of their patients’ risk adjusting conditions. This directly impacts and reduces the payment a health plan receives for government sponsored insurance. What if there was a way to inform the provider about chronic risk adjusting conditions that aren’t included on a claim as it travels through the clearinghouse? This capability does exist and has allowed providers to correct the claim prior to being received by the health plan. This new workflow can reduce the need to perform chart reviews and offer a prospective way to capture risk adjusting conditions, a critical opportunity for Medicaid states that do not allow chart review.
Learn how one health plan:

  • Messaged providers within their existing clearinghouse workflow about missing risk adjustment conditions
  • Educated providers to improve engagement and response
  • Used this prospective program to play a key role in their overall risk adjustment strategy

Jimmy Liu,Vice President, Risk Analytics,Change Healthcare


What Happens When the Programs Your Health Plan Incentivizes Become Non-Essential During a Pandemic?
You Pivot!

In this session we will walk through one approach in the many possibilities and how to maintain engagement in code capture and recapture using the Waiver 1135 telehealth services as they relate to acceptable visit types for risk adjustment. Join us to explore case studies from Rural Health, Federally Qualified Health Centers, Integrated Health System and Risk barring arrangements in a MAO network.

Dawn Peterson,Director of Risk Adjustment,Martin’s Point Health Care


How Risk Adjustment Can Boost Star Ratings through Closing Gaps In Care

Focus on prospective Risk Adjustment programs creates unique opportunities to align Quality and Risk Adjustment strategies. This session with explore strategies to align member and provider engagement efforts across RA and Quality programs to maximize the efficacy of each encounter, improve member and provider satisfaction, and optimize budgets to deliver results.

Dan Weaver,Vice President, Stars, Quality & Risk Adjustment,Gateway Health


Close of Module #3

Module #4
Thursday, September 24, 2020: 2.00pm – 4:00 p.m. ET

Opening Remarks

Jen Hayes,Manager of Quality, HEDIS & Coding,Highmark


Re-educating Providers on Complete & Accurate Coding & Documentation

Since March of this year, volume has declined with patients going into the office for Annual Wellness Visits. Whether the patient has Medicare Advantage, Individual, or a Small Group policy under the Affordable Care Act, Risk Adjustment still exist. To prevent a cataclysmic fall in risk adjustment performance, and to optimize appropriate reimbursement, plans must work more efficiently and effectively with the provider community to ensure chronic conditions continue to be captured. This session will briefly provide ideas of ways to ensure that providers are re-educated on complete and accurate coding and documentation to try to maintain risk scores. Come ready to obtain a lot of information in a short amount of time

Wynda Clayton, MS, RHIT,Risk Adjustment Manager,Providence Health Plan


Incentives and Educational Programs to Garner Physician Engagement -- Exclusive Provider Perspective

As the healthcare system continues to move towards more value based payment models, it is critical to have high provider engagement.  For any risk adjustment program to be successful, the member’s primary care provider must be given the knowledge and motivation to code all chronic conditions to the highest level of specificity.  A best in class prospective risk adjustment program dedicates the appropriate risk adjustment coding experts and the proper financial incentives.

Michael Zeli,Director of Risk Adjustment & Quality for the Population Health Services Organization,AdventHealth

Revenue Reconciliation and Interdepartmental Alliances

Aligning Risk Revenue with Stars & QA/HEDIS

Shelley Stevenson, Director, Government Programs Practice, Change Healthcare Consulting


CASE STUDY: Interdepartmental Committee Structures and Strategies to Reduce Redundancies and Streamline Operations

Many health plans struggle with where to place the risk adjustment department within the organization since there is overlap with both finance and quality. At Health Alliance, we use a sub-committee structure. In this session we will share how we created this structure, the wins, and the challenges. Join us to share your plan’s experience with this technique, ask questions and discuss the pros and cons of this approach with your peers.

Zoe Lutes, Director of Utilization Management & Risk Adjustment, Health Alliance


Turning Diagnosis Codes into Dollars: From Claims to HCC to Risk Score

  • Increase recapture rate
  • Decrease number of members with no HCCs
  • Identify Suspect HCCs Using Longitudinal Record Reviews
  • Expanding retrospective chart reviews including chart retrieval

Pramada Prabhakaran,Manager, Risk Adjustment,NAMMCA

Melody Noelke,Operations Manager, Risk Adjustment,NAMMCA


Close of Conference