Empirical Risk Management

Phone: 772-210-2823

Fax: 772-210-2824

 

Kameron Gifford, CPC

772-267-9453

 

Todd Gifford, MBA

772-267-8156

ERM has a NEW Blog:

MRA Alert

Is your organization looking for ways to improve operations at the practice level?
If so, ERM has an evidence based process "Rapid Practice Innovation" that has been tested in Medicare, Medicaid, Commercial and ACO populations. 

 

ERM's proven process implements change at the intial point of contact to optimize risk adjustment processes and clinical quality measures.

 

We will work hand in hand with frontline staff to build internal programs or enhance your current initiatives. 
 

Contact Kameron Gifford today to learn more about RPI.

 

 

Preliminary Results have already shown a 500% Return on Investment in 12 months without auditing a chart. 

 

Todd Gifford, MBA

Kameron Brown, CPC

www.empiricalriskmanagement.com

Empirical Risk Management was founded in 2012 as a subsidy of ERM Consulting, Inc.

Executive Summary

Empirical Risk Management is an evidence based process of identifying, managing, documenting and improving quality of care. Our proprietary model of risk adjustment will help managed care organizations streamline their operations, reduce costs and improve outcomes.

Empirical Risk Management is formed around the concepts of teamwork, partnership, service, and quality, both in the coordination of our efforts and in our interactions with our clients and their respective members.

ERM’s Distinctive Business Model

ERM’s trademarked methodology combines education and compliance to create fundamental change that ultimately improves the standard of care.

 

Initiating Change From Origin to End Point

Increased demand for health care services, the growing complexity and cost of medical claims coding, and a shortage of experienced medical professionals already pose serious financial and compliance challenges to both health plans and physician practices. The Centers for Medicare and Medicaid Services estimates that by 2021, US healthcare costs will reach $5 trillion, or 20 percent of Americas GDP.  Over the next 25 years the Congressional Budget Office estimates, population aging will be responsible for 52 percent of all federal spending on healthcare programs. For these reasons, the government remains steadfast in their plight of reform and oversight. This “perfect storm” undoubtedly has the potential to disrupt heath care operations around the country in the months and years to come.

Without a doubt, the best defense is a strong offense. Empirical Risk Management offers specialized services to managed care organizations, accountable care organizations and physicians. Our prospective system of education and compliance will not only prepare our clients for the future but will protect them as well.

The Centers for Medicare and Medicaid Services recently updated the “Medicare Managed Care Guide” to reflect new initiatives. As of February 28, 2012, health plans and all down-stream entities must ensure regulatory compliance through due diligence and oversight activities.

The Office of Inspector General 2013 Work Plan reiterates these objectives.

2013 HHS Work Plan

Encounter Data—CMS Oversight of Data Integrity (New)

We will review the extent to which MA encounter data reflecting the items and services provided to MA plan enrollees are complete, consistent, and verified for accuracy by CMS.  In 2012, MA encounter data reporting requirements will expand from an abbreviated set of primarily diagnosis data to a more comprehensive set of data.  (One Time Notification, Pub. 100-20, CR 7562.) Prior CMS and OIG audits have indicated vulnerabilities in the accuracy of risk adjustment data reporting by MA organizations.  (OEI; 00-00-00000; expected issue date:  FY 2014, new start)

Risk Adjustment Data—Sufficiency of Documentation Supporting Diagnoses 

We will determine whether the diagnoses that MA organizations submitted to CMS for use in CMS’s risk-score calculations complied with Federal requirements.  We will review the medical record documentation to ensure that the documentation supports the diagnoses submitted to CMS.  Payments to MA organizations are adjusted on the basis of the health status of each beneficiary.  (Social Security Act, §§ 1853(a)(1)(C) and (a)(3).)  MA organizations submit risk adjustment data to CMS in accordance with CMS instructions.  (42 CFR § 422.310(b).)  (OAS; W-00-09-35078; W-00-10-35078; various reviews; expected issue date:  FY 2013; work in progress)

 

 

Risk Adjustment Data—Accuracy of Payment Adjustments

We will determine whether CMS properly adjusted payments to MA plans on the basis of the results of its data validation reviews.  Risk adjustment data validation is an annual process of verifying diagnosis codes.  (42 CFR §§ 422.308(c) and 422.310(e).)  The process affects payments to MA plans.  CMS contracts with Quality Improvement Organizations (QIO) or equivalent contractors to verify whether diagnosis codes are supported by medical record documentation.  (OAS; W-00-12-35554; various reviews; expected issue date:  FY 2013; work in progress)

Provision of Services—Compliance With Medicare Requirements

We will review MA organizations’ oversight of contractors that provide enrollee benefits, such as prescription drugs and mental health services.  We will determine the extent to which MA organizations oversee and monitor their contractors’ compliance with regulations and examine the processes they use to ensure that contractors fulfill their obligations.  MA organizations are accountable for the performance of the entities with which they contract.  MA organizations that delegate responsibilities under their contracts with CMS to other entities must specify in their contracts with those entities provisions that the entities must comply with all applicable Medicare laws, regulations, and CMS instructions.  (42 CFR § 422.504(i)(4)).

Compliance is no longer an optional expense in health care. Empirical Risk Management provides comprehensive solutions to reduce liability and improve outcomes.

Scope of Services

Empirical Risk Management’s primary objective is to provide health care organizations with a superior process of providing, documenting, coding, funding and improving the care of its members. Our education and compliance programs provide an efficient system to keep clients competitive and compliant by confirming their HCC based average Risk Adjustment Factor (RAF) score matches their members’ actual health risk.

Empirical Risk Management offers the following comprehensive consulting services:

• Multiplatform Education and Training for Providers and Patients
• State Specific Representation involving Mergers and Acquisitions
• Innovative Systems and Processes to Improve Quality
• Auditing and Compliance in accordance to OIG Standards
• Implementation and Monitoring of Initial Health Assessments and Annual Preventive Services
• HEDIS and Star Improvement Programs
• Digitized Medical Record Acquisition and Storage

 

 

 

 

 

 

 

Mergers and Acquisitions

An estimated 21 percent of self-employed physicians will sell their practices in 2013. This trend initiated by the ACA has helped to create exceptions to restrictive legislation such as Corporate Practice of Medicine policy. Twenty-one physician practices reported mergers and acquisitions in the second quarter of 2012, with $4.2 billion changing hands. Empirical Risk Management delivers state specific guidance to ensure compliance and defend your investment.  The Centers for Medicare and Medicaid services issued new guidance on this in February of 2012 in which they strongly suggest that mergers and acquisitions be handled by third party entities. Empirical Risk Management, offers transparency and adds value through due diligence and oversight. Systematic processes ensure compliance with all local, state and federal regulations. ERM specializes in states with restrictive covenants such as Corporate Practice of Medicine Policy.

Texas M&A Information attached.

 

MyMD365.com

Empirical Risk Management continually strives to improve the quality, access, and delivery of care today. These efforts have fostered the creation of conceptual innovations in both systems and processes. Specifically, MyMD365.com , intellectual property of ERM Consulting Inc, which strategically integrates independent technologies into a single point of access. This disruptive solution will allow quality health care to be delivered anytime, anywhere to anyone.

Complete conceptual design attached.

 

Provider Education and Compliance

Risk Adjustment - Twelve Month Design

ERM’s initial design focused around improving quality through increased education, compliance and regulatory efforts. By applying these principles to a risk adjusted population we have created a systematic process that can be implemented again and again without regard to any specific population or market characteristics.

The preliminary results of ERM’s first pilot have already shown a 15% positive change in less than twelve months. The complete report is attached.

 

Education

Empirical Risk Management offers comprehensive provider education utilizing multiple methods of instruction to implement change from origin to end point.

Annual Education

Annual education and training will be organized to meet all local, state and federal standards. These will include annual HIPPA and compliance training for all downstream and related entities. CME can be offered for multiple organizations including, AAPC, AAFP, TMLT and PMI.

Quarterly Education Meetings

Quarterly education meetings will be organized for all contracted physicians with topics to include MRA, HCC documentation and coding, regulatory updates and compliance standards. Quarterly meetings will include a presentation and educational handouts to assist providers in current correct coding and documentation standards or other educational topics.

Individual Education

Empirical Risk Management will develop specialized educational plans targeted towards individual deficiencies indentified in medical record review. The specific needs of providers will be addressed to correct and prevent future errors. 

 

 

ICD-10 Preparation

 

The October 1, 2014 implementation date for ICD-10 is quickly approaching. Empirical Risk Management can assist your organization in preparing for this transition. The greatest barrier to the new coding system will be incomplete or insufficient documentation. Start preparing now. ERM’s services included evaluation of electronic medical records and individualized e-learning modules as well as onsite education and training.

 

 

Compliance

Empirical Risk Management will develop and implement an effective compliance plan to include all downstream entities and related entities. A compliance committee will be established and a central hotline will be created. Compliance training will be initiated for all providers and training logs will be submitted to the plan as required in 42 CFR 422. Quarterly compliance meetings will be held to address any potential risks or liabilities. The compliance committee will be responsible for developing, implementing and monitoring corrective action plans.

As recommended by the OIG Healthcare Fraud and Prevention Enforcement and Action Team a baseline audit will performed. Empirical Risk Management’s audit procedures meet all CMS requirements as defined in CMS publication “Final Payment Error Calculation Methodology for Medicare Advantage RADV Audits” published February 24, 2012.

Sample compliance plan attached.

 

Chart Auditing

Empirical Risk Management will retrieve and audit medical records for the purpose of medical risk adjustment validation and education. We will perform consistent reviews of coding and documentation to ensure accuracy and reduce financial risks.

Internal auditing and monitoring are the most effective tools for managed care organizations to comply with “due diligence” mandates.  These efforts realize the federal government’s initiative to prevent fraud, waste and abuse while creating an effective tool to identify and target specific needs in provider education.

Sample Baseline Audit attached.

 

Electronic Monthly Newsletters

Monthly newsletters will be distributed to all providers highlighting specific areas of interest in coding, documentation, compliance, and education.

Torch of Excellence attached as an example.

Patient Education

Patient education is essential to quality improvement efforts. Classes will be developed to meet the unique needs of each member population. Providers will be notified of available classes and members will be invited to participate. Available topics include: Controlling Diabetes, InsulinTraining, Medication Compliance, Care Planning, and Smoking Cessation.

“A Fair For The Heart” patient flyer attached.

 

Initial Health Assessments

Annual health assessments will be developed to include all required elements of the Medicare Initial and Annual Wellness exams. The assessments will be conducted by the Primary Care physician who each member is assigned. The assessments will be submitted annually as an encounter and appropriate documentation will be forwarded to the plan. All HCC diagnoses captured within the last 12 months will be available for the PCP’s review prior to the patient’s exam.

 

Sample Health Assessment Attached.

 

 

 

 

 

 

 

HEDIS and STAR Improvement Efforts

Measuring health care performance is critical for managed care organizations to evaluate the level of service their providers deliver, identify performance gaps and make any needed changes to cultivate continued member satisfaction and loyalty. HEDIS and STAR ratings were considered in great detail throughout the development of our methodology. Every aspect of our process works to enhance both measures. Our HEDIS review covers 74 measures across 8 domains. Score cards are provided for each measure identified.

 

A Complete Solution

Empirical Risk Management understands what healthcare organizations, physicians and patients need, and we can provide the process and expertise that will deliver results.

 

 

 

 

 

 

 

 

 

 

Focuses on Three Specific Areas of Improvement

Providers

Quarterly Meetings

 Group meetings with providers to address specific goals, coding and documentation updates, market updates, and any other general business. These will be held every 90 days.

Individual Education / Auditing

Individual education is offered on site and through our online services. Contact us for more information. These are as needed.

 

Office Staff

Coding Classes will be offered to all office staff to reinforce the education that the physician is receiving. Handouts, coding “cheat sheets” and Annual Documentation and Coding Guides will be given to all office attending. Power Point presentations will also be available in both digital and print format.

 

Patient Education

Health Fairs and other community events will organized to further enhance the patient experience and engagement. These events will work with contracted providers and local community resources to promote prevention and wellness for everyone.

Individual Education / Group Education

Specific Education focusing on topics such as Insulin Management, Diabetic Foods, Weight Loss, Group Counseling, and Chronic Disease Management can be organized as needed at anytime.

 

 

 

 

 

 

Each provider’s members would be ranked by risk score, and then divided into three equal groups to represent high, medium and low strata. An equal number of members (7.3%) will be randomly selected from each group.

Providers will be notified of their patients selected for the baseline audit and a time to collect records will be scheduled. Medical record specialist will retrieve the records from the physician’s site and submit them for review and analysis via fax to an automatic server. The images of the medical records would then be available for review by our certified coders and the client.

 

The audit results would then be analyzed and providers scored on their error rates.

The error rate on the baseline audit would determine future reviews.

 

Error Rate	Schedule for Follow-up Audits
10% or less	Annual
10% - 20%	Five Months
20% - 30%	Four Months
30% - 40%	Three Months
40% to 50%	Two Months
50% or more	One Month

 

These scores would then be used to identify providers most at risk. These individuals will be contacted and meetings will be scheduled to discuss the findings of the audit.  Any provider with an error greater than 10% will be placed on a corrective action plan consistent with OIG recommendations. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Market Characteristics:  13,500   Medicare Advantage Members

Optional Participation: – 75 Primary Care Practices

·         41 Practices Participated / Representing 8,714 Members

 

Classes were held during lunch in an effort to provide the greatest opportunity for attendance. Participants were offered lunch and provided with copies of the presentations and other coding and documentation guides.

Methodology- focused on designing an integrated, replicable, process of education and improvement in managed care populations.

Goal: Improving quality of care while reducing costs through education and compliance only.

ERM identified specific areas of coding deficiencies, over utilization and gaps in the continuum of care that negatively affected funding. A curriculum was developed and then adapted to address three specific audiences: providers, office staff and patients.

Curriculum:  Coding Compliance and Sun Tzu Volume  I and II.  

Coding Compliance and Sun Tzu Volume 1 – Centers on diabetes and diabetic manifestations.  Topics covered include early identification and prevention, compliant documentation, coding improvement, disease management, and best practices.

 

Coding Compliance and Sun Tzu Volume II – Centers on cardiovascular disease and prevention. Topics covered include early identification and prevention, compliant documentation, coding improvement, disease management, and best practices.

Live Education

Empirical Risk Management builds custom educational modules specifically designed for each audience.

Providers – Providers attended quarterly PCP dinners.  These dinners focused on specific areas of improvement and offered a forum for feedback and discussion.  Power point presentations, quick coders and documentation guides were created to give uniformity across the market. Providers embraced these educational opportunities and invited us into their offices for individual education.

 

               

 

One on One Provider Education – Individualized practice assessments found issues ranging from outdated superbills to inefficient processes. ERM worked with the physicians to improve operations, increase revenue, and safeguard their practice.

                                                         

 

Office Staff – Office staff attended two hour educational events every quarter. These lunches focused on specific areas of improvement and offered a forum for feedback. Power point presentations, quick coders and documentation guides were created to give uniformity across the market. Office staff also received annual training in compliance, HIPPA, fraud waste and abuse and other mandated education.

Patient Education – Community health fairs were designed to target a specific disease state. In synchrony with Coding, Compliance and Sun Tzu Volumes 1 and 2 the health fairs focused on Diabetes and Heart Disease. These actions reinforced what we were teaching the providers and office staff. A great deal of research and time was invested in these events to bring the greatest amount of community resources together.

 In addition to providing education, these events promote goodwill on behalf of the sponsor by bringing awareness to the community. An unexpected outcome of the health fairs was very positive media coverage. All major television stations and local newspapers covered the wellness expos.

 

Outcomes

Control Group A -  Medicare HMO group X

26 Primary Care Practices representing 4,813 members or 35% of the population.

The control group’s combined MRA was 0.97 at the beginning of Month 1.

At the end of Month 12, the combined MRA for the control group had increased to 0.98

 

Group B – Medicare HMO group X

41 Primary Care Practices representing 8,714 members or 65% of the population.

This group’s combined MRA was 0.94 at the beginning of Month 1.

 

 

Data – Control Group A

CENTER	Members	MRA - Month 1	MRA -   Month 12	Projected MRA -Month 13	MRA Change
Provider A	222	0.86	0.87	Month 13	0.04
Provider B	278	0.88	0.91	0.89	-0.02
Provider C	57	0.99	0.97	0.93	-0.05
Provider D	22		1.18	1.02	-0.19
Provider E	212	0.96	0.83	0.89	0.07
Provider F	299	0.92	0.88	0.87	0.00
Provider G	390	1.01	1.09	1.17	0.09
Provider H	96	0.84	0.75	0.85	0.11
Provider I	350	1.01	1.02	0.96	-0.03
Provider J	61	1.03	0.82	0.76	-0.04
Provider K	93		1.23	1.19	-0.04
Provider L	643	0.99	0.94	1.01	0.07
Provider M	84		0.87	0.9	0.03
Provider N	176	1	0.86	0.91	0.07
Provider O	100	0.75	0.8	0.77	-0.03
Provdier P	227	0.94	0.88	0.83	-0.05
Provider Q	126	0.96	0.81	0.83	0.01
Provdier R	32	0.9	1.11	1.05	0.10
Provider S	61	1.29	1.13	1.2	-0.02
Provider T	93	0.89	0.87	0.96	0.09
Provider U	495	1.12	1.05	0.97	-0.08
Provider V	483	0.98	1.13	1.3	0.17
Provider W	15	0.56	1.25	1.16	0.11
Provider X	24	1.08	1.24	0.85	-0.32
Provider Z	174	1.44	1.34	1.44	0.13
Totals	4,813	0.97	0.99	0.98	0.01

 

 

 

 

 

 

 

 

Empirical Risk Management’s Data – Group B

CENTER	Members	MRA -     Month 2	MRA -      Month 12	Projected MRA - Month 13	MRA Change
Provider 1	320	1.12	1.06	1.01	-0.05
Provider2	162	0.95	0.80	0.88	0.09
Provider3	61	0.93	1.08	1.20	0.12
Provider4	70	0.73	0.80	0.87	0.11
Provider5	340	0.98	1.06	1.12	0.08
Provider6	88	0.83	0.86	0.99	0.13
Provider7	105	0.88	0.92	0.85	0.00
Provider8	30	0.81	0.80	0.99	0.17
Provider9	325	0.96	0.96	0.95	-0.01
Provider10	349	0.91	0.91	0.90	-0.01
Provider11	20	0.54	0.87	0.93	0.17
Provider12	340	0.94	0.95	0.98	0.04
Provider13	92	0.82	0.79	0.87	0.08
Provider14	532	0.93	0.90	0.96	0.08
Provider15	203		0.90	0.88	-0.02
Provider16	112	1.01	1.04	1.04	0.02
Provider17	225	1.03	0.97	1.05	0.08
Provider18	954	0.9	0.86	1.12	0.26
Provider19	117	0.8	0.68	0.78	0.09
Provider20	84	0.95	0.86	0.90	0.02
Provider21	562	0.93	0.96	1.34	0.38
Provider22	177	0.87	0.80	0.96	0.19
Provider23	284	0.96	0.94	1.05	0.11
Provider24	68	1.09	1.19	1.21	0.05
Provider25	149	1.49	1.31	1.25	-0.09
Provider26	299	0.97	1.11	1.69	0.58
Provider27	114	1.01	0.98	1.07	0.09
Provider28	31	1	0.93	0.99	0.11
Provider29	99	0.88	0.89	1.07	0.19
Provider30	143	0.72	0.73	0.75	0.03
Provider31	89	0.97	1.11	1.18	0.10
Provider32	263	0.95	1.07	1.07	-0.02
Provider33	190	0.91	0.94	0.99	0.05
Provider34	90	1.18	1.11	1.13	0.00
Provider35	161	0.94	0.90	0.97	0.09
Provider36	172	0.96	1.04	1.18	0.11
Provider37	111	0.89	0.77	0.76	0.00
Provider38	327	1.1	1.07	1.12	0.05
Provider39	46	1.12	1.13	1.11	-0.01
Provider40	572	0.95	0.89	0.91	0.05
Provider41	238	0.91	0.91	1.04	0.13
Totals	8,714	0.94	0.95	1.04	0.09

 

 

 

Return on Investment –

Total Expense $150,000

To find the most accurate ROI we looked at the change in MRA vs. positive change in funding. By determining the value of a basis point we were able to analyze cost vs. return.

A positive change of 2 basis points resulted in an 11 million dollar increase in funding.

With this information we can estimate that funding for Month 13 will reflect an annual increase in funding by $49 million; roughly $4 million per month.