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


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


Auditing for RADV Compliance – New Procedures Post Pandemic

Donna Malone, CPC, CRC, CRC-I, AHCCA, RAP,AAPC Approved Instructor, Director Coding &Provider Education (CDI), Enterprise Risk Adjustment,Tufts 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

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


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

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


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

What Happens When the Programs Your Health Plan Incentives 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

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

Coding Accuracy – Complete & Accurate Documentation

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

Panel Discussion: Aligning Risk Revenue with Stars & QA/HEDIS


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


Close of Conference