CY18 National RADV Training Teleconference Overview
The CY18 National RADV Training Teleconference held on February 13, 2020, provided an overview of the program transition, agenda details, and introductions of key personnel. Topics covered included HPMS overview, sample overview, medical record processes, CMS-generated attestations, and important reminders. The session concluded with a Q&A session and final reminders.
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CY18 National RADV Activity Calendar Year 2018 National Risk Adjustment Data Validation (CY18 National RADV) Medicare Advantage (MA) Organizations Training Teleconference February 13, 2020 1:00 p.m. 3:00 p.m. ET Web link: https://religroupinc.webex.com/religroupinc/onstage/g.php?MTID=e6b006c2e31ea4f9cf9b68d06ec8b5b20 https://religroupinc.webex.com/religrou pinc/onstage/g.php?MTID=e6b006c2e31 ea4f9cf9b68d06ec8b5b20 Audio Access: 1-408-418-9388 Access Code: 796 214 400 https://religroupinc.webex.com/religroupinc/onstage/g.php?MTID=e6b006c2e31ea4f9cf9b68d06ec8b5b20 https://religroupinc.webex.com/religroupinc/onstage/g.php?MTID=e6b006c2e31ea4f9cf9b68d06ec8b5b20
Logistics WebEx Features To expand your display to full screen, select the double arrow in the top right corner of the event screen To submit questions during the teleconference, select the Q&A feature and enter your question Questions asked using this feature will be answered at the end of the demonstration Technical Assistance For questions regarding logistics or registration, please contact Registration Support Phone: 1-443-961-2549 Email: webevents@religroupinc.com February 13, 2020 CY18 National RADV 2
Welcome & Introductions Centers for Medicare & Medicaid Services (CMS), Payment Accuracy & Reporting Group (PARG), Office of Financial Management (OFM) Chrissy Fowler, Group Director Benjamin Moll, Deputy Group Director Carolyn Kapustij, Team Lead Joanne Davis Darlene Anderson Megan Curran February 13, 2020 CY18 National RADV 3
Welcome & Introductions National RADV transitioned from Center for Medicare (CM) to OFM in 2019 National RADV = Part C Improper Payment Measure (IPM) After CY18, CMS will refer to the program as Calendar Year 2019 Part C Improper Payment Measure February 13, 2020 CY18 National RADV 4
Agenda 1. CY18 National RADV Overview 2. Health Plan Management System (HPMS) Overview 3. CY18 National RADV Sample Overview 4. Medical Record Request Process 5. Medical Record Submission Process 6. CMS-Generated Attestations 7. Preparing the Medical Record Submission Files 8. Receipt and Review of the Medical Records 9. Medical Record Submission Feedback 10. CY18 National RADV Important Reminders and Contact Information 11. HPMS Demonstration 12. Question & Answer Session 13. CY18 National RADV Final Reminders February 13, 2020 CY18 National RADV 5
CY18 National RADV Overview February 13, 2020 CY18 National RADV 6
CY18 National RADV Overview Conducted by CMS to meet the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payment Elimination and Recovery Act of 2010 (IPERA) and further amended by the Improper Payments Elimination and Recovery Improvement Act of 2012 (IPERIA) IPERIA requires that government agencies: Identify programs at risk for improper payments, Estimate the annual amount of improper payments for the programs, and Report the annual estimates to Congress February 13, 2020 CY18 National RADV 7
CY18 National RADV Overview (continued) Objectives Verify CMS-Hierarchical Condition Categories (HCCs) used for CY18 payments sampled in NAT18 RADV Identify risk adjustment payment errors Calculate a Part C National improper payment estimate Method CMS substantiates all payment CMS-HCCs for all sampled enrollees by reviewing hospital (inpatient & outpatient) and physician office medical records submitted by MA Organizations For CY18 payments, CMS-HCCs are determined by International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) codes February 13, 2020 CY18 National RADV 8
CY18 National RADV Overview (continued) Summary of Tasks: Identify sample plans and the enrollees and their CMS-HCCs selected in the sample Submit medical record supporting documentation Conduct medical record review Calculate Medicare Part C payment error rate February 13, 2020 CY18 National RADV 9
CY18 National RADV Overview (continued) Timeline: January 13, 2020: MA Organizations notified February 13, 2020: CY18 National RADV MA Organizations Training Teleconference February 14, 2020: Medical record submission window opens April & May 2020: Interim Findings Reports (IFR) #1 and #2 released June 8, 2020: Submission window closes February 13, 2020 CY18 National RADV 10
Health Plan Management System (HPMS) Overview February 13, 2020 CY18 National RADV 11
HPMS Overview HPMS is a secure online system which provides MA Organizations the ability to download information and upload medical record documentation HPMS is CMS only acceptable method for delivery and receipt of CY18 National RADV data HPMS will allow users authorized by MA Organizations to access the system HPMS will enable MA Organizations to access the Medical Record Coversheets in electronic format HPMS will enable MA Organizations to view all submitted documentation February 13, 2020 CY18 National RADV 12
CY18 National RADV Sample Overview February 13, 2020 CY18 National RADV 13
CY18 National RADV Sample Overview NAT18 RADV Sample: Cohort: January 2018 MA contracts and enrollees Data Collection Period: January 1, 2017 through December 31, 2017 dates of service Eligible Contracts: Active MA contracts that received risk-adjusted payments and did not terminate or consolidate in 2017, 2018, 2019, or 2020 February 13, 2020 CY18 National RADV 14
CY18 National RADV Sample Overview (continued) NAT18 RADV Stratified Random Sample: Strata based on distribution of the disease (or CMS-HCC) component of the risk score across eligible enrollees in all eligible MA contracts An equal number of enrollees was sampled from three strata representing high, medium, and low risk score ranges A total of 930 beneficiaries was randomly sampled from across all eligible MA contracts From each stratum, 310 enrollees were sampled February 13, 2020 CY18 National RADV 15
CY18 National RADV Sample Overview (continued) Eligible Enrollees for NAT18 RADV: 12 months of Medicare Part B during data collection year (i.e., Full-Risk) Continuously enrolled in the same contract from January 2017 through January 2018 Non-End State Renal Disease (ESRD) from January 2017 through January 2018 (no payment made based on the ESRD-HCC Model) No hospice status (resulting in one or more eliminated monthly risk-adjusted payments) from January 2017 through January 2018 At least one CMS-HCC assigned and used for payment in CY18 February 13, 2020 CY18 National RADV 16
CY18 National RADV Sample Overview (continued) 1. Access the following files in the National RADV Document Library in HPMS CY18 National RADV Medical Record Submission Instructions Enrollee List Enrollee List Data Dictionary Hospital and Provider Letters CMS-Generated Attestations Gather medical record documentation from providers Prepare medical record files Complete the electronic Medical Record Coversheets in HPMS Upload medical record files to HPMS National RADV module Check uploaded files for accuracy Refer to CY18 National RADV Medical Record Submission Instructions as needed and adhere to all deadlines 2. 3. 4. 5. 6. 7. February 13, 2020 CY18 National RADV 17
CY18 National RADV Sample Overview (continued) Contents of CY18 National RADV Medical Record Submission Instructions: National RADV Background and Requirements Requesting Medical Records from Providers Medical Record Selection Criteria CMS-Generated Attestations Preparing the Medical Record File Checking the Medical Record File Before Submission Feedback Available Within HPMS Contact Information February 13, 2020 CY18 National RADV 18
CY18 National RADV Sample Overview (continued) Enrollee List: Includes CMS-HCC documentation containing enrollee information in Microsoft Excel format Majority of data elements in the enrollee list are also present on the Medical Record Coversheet within HPMS and the HPMS- Generated Enrollee-HCC Report Contains supplemental Medicare Beneficiary Identification (MBI) information (Enrollee HIC & Railroad Retirement Board HIC (RRBHIC) Number) to cross-reference against the CMS master enrollment databases Each row in the file lists a unique CMS-HCC for an enrollee Every CMS-HCC on the Enrollee List must be validated, even if there February 13, 2020 are multiple CMS-HCCs in the same hierarchy CY18 National RADV 19
CY18 National RADV Sample Overview (continued) Enrollee List Data Dictionary: Description of each data element present in the enrollee list Listed in the same order in which the variables appear in the enrollee list Three columns in the data dictionary: Column 1 The order the variable appears Column 2 Data Element/Label Column 3 Description Can be used in conjunction with the enrollee list if details are needed about a specific variable February 13, 2020 CY18 National RADV 20
Medical Record Request Process February 13, 2020 CY18 National RADV 21
Medical Record Request Process The medical record: is documentation of a single face-to-face encounter with a physician/practitioner is not the enrollee s entire medical record for the period beginning January 1, 2017 through December 31, 2017 Types of medical records: Physician and Outpatient A specific date of service (e.g., March 6, 2017) Inpatient A specific admission beginning on the admission date through the discharge date (e.g., July 22, 2017 through July 25, 2017) February 13, 2020 CY18 National RADV 22
Medical Record Request Process (continued) At a minimum, medical records must meet the following requirements to avoid a discrepant finding: Acceptable risk adjustment provider type and physician specialty Date of service within the data collection period January 1, 2017 through December 31, 2017 Valid signature and credentials If missing, use CMS-Generated Attestation Correct beneficiary February 13, 2020 CY18 National RADV 23
Medical Record Request Process (continued) MA Organizations may use the Provider Letters, Hospital Letters and HIPAA Fact Sheet when requesting medical records from providers These materials must only be used for the purposes of the NAT18 RADV Ensure your contact information is included on the request If pages are separated during the request process, a provider can reach out to you Providers should not contact CMS directly February 13, 2020 CY18 National RADV 24
Medical Record Request Process (continued) Safeguard Protected Health Information and Personally Identifiable Information (PHI/PII), when requesting medical records from providers: Limit disclosure of enrollee identifiable health information to minimal information necessary to accomplish the intended purpose of this request Only send specific enrollee health condition information to the providers responsible for treating the enrollee for those conditions Instruct providers to send medical records to your MA Organization providers should not send any medical records directly to CMS or upload into HPMS National RADV module. Only your MA Organization s authorized users may upload medical records to the HPMS National RADV module Provide reasonable deadlines for providers to respond (CMS allows MA Organizations 16 weeks for submissions via the HPMS National RADV module) February 13, 2020 CY18 National RADV 25
Medical Record Submission Process February 13, 2020 CY18 National RADV 26
Medical Record Submission Process MA Organizations must select a corresponding medical record to support each sampled CMS- HCC being validated You may have one or multiple medical records to support a specific CMS-HCC More than one CMS-HCC may be designated on the Coversheet for a single medical record CMS will review each medical record to validate the CMS-HCC(s) indicated on the Medical Record Coversheet February 13, 2020 CY18 National RADV 27
Medical Record Submission Process (continued) It is important to submit a medical record for every CMS-HCC If you have a medical record that you believe does not support the exact CMS-HCC being validated or a medical record supporting a CMS-HCC within the same hierarchy, we recommend that you submit the medical record for review as we may find that the medical record does support the CMS-HCC Submit only one medical record per Medical Record File February 13, 2020 CY18 National RADV 28
Medical Record Submission Process (continued) Additional Medical Record Files (i.e., replacement records) for a sampled CMS-HCC may be submitted up until the submission deadline If supporting medical record documentation for the enrollee s sampled CMS-HCC cannot be provided, medical record documentation supporting another CMS- HCC within the same hierarchy may be submitted under the same Coversheet Refer to Section 3 of the CY18 National RADV Medical Record Submission Instructions February 13, 2020 CY18 National RADV 29
Medical Record Submission Process (continued) Purpose of Medical Record Coversheet: Track and monitor the submission of medical records Confirm the record belongs to the enrollee Identify the CMS-HCC(s) under review Identify the different documentation (i.e., medical record and attestation) to be considered for review Indicate which ICD-10-CM coding guidelines should apply (inpatient or physician/outpatient) Define the date of service or range of dates to be reviewed February 13, 2020 CY18 National RADV 30
Medical Record Submission Process (continued) Completing a Medical Record Coversheet in HPMS: In the Designated CMS-HCC list, check the box for each CMS-HCC(s) applicable to this submission. You may designate multiple CMS- HCCs on a single Coversheet Select the option that applies to the designated CMS-HCC(s) for this enrollee Submit Document (Medical Record or Medical Record with Attestation) No Document to Submit (No Medical Record) Designated area available for corrections to Enrollee Date of Birth, Last Name or First Name Select the Document Type Physician/Specialist/Hospital Outpatient/Observation Hospital Inpatient February 13, 2020 CY18 National RADV 31
CMS-Generated Attestations February 13, 2020 CY18 National RADV 32
CMS-Generated Attestations CMS-Generated Attestations may be used to address problematic or missing signatures and/or credentials on outpatient medical record submissions CMS-Generated Attestations are voluntary CMS-Generated Attestations are simple to complete and submit but must meet CMS requirements CMS-Generated Attestations provide the option for MA Organizations to correct signature and credential issues on medical records that the MA Organization indicates on the Coversheet are to be coded according to physician/outpatient coding guidelines Complete the CMS-Generated Attestation form according to the CY18 National RADV CMS-Generated Attestation Instructions provided in the National RADV Document Library in HPMS MA Organizations are given one CMS-Generated Attestation per enrollee in the CY18 National RADV encrypted enrollee data package located in the National RADV Document Library in HPMS February 13, 2020 CY18 National RADV 33
CMS-Generated Attestations (continued) If more than one attestation is needed, MA Organizations should print multiple forms Completed CMS-Generated Attestations should be submitted to CMS according to the CMS-Generated Attestation Instructions provided in the National RADV Document Library in HPMS Submit CMS-Generated Attestation (if applicable): Check attestation to be sure it meets CMS requirements If it does not meet CMS requirements, decide whether to request another attestation from the physician/practitioner Create a PDF containing the attestation and medical record collectively called the Medical Record File Submit the Medical Record File via the National RADV module in HPMS February 13, 2020 CY18 National RADV 34
CMS-Generated Attestations (continued) If a physician/practitioner submits medical records without signatures and/or credentials for more than one CMS-HCC, you must obtain individual CMS-Generated Attestations corresponding to each medical record and date of service Are only allowed for medical records that the MA Organization indicates on the Medical Record Coversheet are to be coded according to physician/outpatient coding guidelines Must not be altered or edited Must only be signed by the physician/practitioner whose medical record is being submitted Must complete all blanks indicated Date of Service on the attestation and medical record must match Must not use MA Organization-generated attestations February 13, 2020 CY18 National RADV 35
CMS-Generated Attestations (continued) Attestation contains two sections: I. Enrollee demographic information (pre-populated) Name DOB MBI HICN MA Contract name and Contract ID (H- or R-number) II. Attestation statement To be completed by the physician/practitioner February 13, 2020 CY18 National RADV 36
CMS-Generated Attestations (continued) CMS-Generated Attestation will be reviewed for validity and may be deemed invalid because of the following: Date of Service Mismatch (Date of service on medical record and coversheet differs from that on the CMS-Generated Attestation) Unacceptable Credentials Unacceptable Signature Attestation Incomplete Attestation Altered (Changes to any pre-populated information) Inpatient Record Not Legible Incorrect Enrollee Non-CMS-Generated Attestation February 13, 2020 CY18 National RADV 37
Preparing the Medical Record Submission Files February 13, 2020 CY18 National RADV 38
Preparing the Medical Record Submission Files Do not submit extraneous documents (e.g., business cards, adhesive notes, coding/clinical evaluations, or coding documents) Do not write on or mark the medical records Do not highlight the medical records Do not submit electronic medical record system screen shots in lieu of a medical record Select a medical record and submit it according to the CY18 National RADV Medical Record Submission Instructions Each Medical Record File should contain: 1. CMS-Generated Attestation, if applicable 2. Supporting medical record Each Medical Record File can only contain one CMS-Generated Attestation and one corresponding medical record February 13, 2020 CY18 National RADV 39
Preparing the Medical Record Submission Files (continued) Each Medical Record File must meet the following criteria: Must be a PDF File File name is less than 100 characters File size is less than 50MB PDF is not password protected PDF does not have bookmarks or binders PDF is not locked for editing PDF is not encrypted If any of the criteria are not met, an error message is displayed with the failure reason on the top of the screen Upon successful submission, a confirmation message will display on the top of the page February 13, 2020 CY18 National RADV 40
Preparing the Medical Record Submission Files (continued) Summary of Medical Record Submission Process: Review the NAT18 RADV Enrollee List, CMS-Generated Attestations, and Hospital and Provider Letters in the National RADV Document Library in HPMS Request medical records and attestations for CMS-HCCs using hospital and provider letters (each containing a HIPAA fact sheet as the second page), and CMS-Generated Attestations (if applicable) Have the physician/practitioner complete the CMS-Generated Attestation, if applicable Choose a medical record for submission Create a file containing PDF images of the CMS-Generated Attestation (if applicable) and related medical record Log in to the National RADV module within HPMS, complete the Medical Record Coversheet and attach and submit the correct Medical Record File February 13, 2020 CY18 National RADV 41
Receipt and Review of the Medical Records February 13, 2020 CY18 National RADV 42
Receipt and Review of the Medical Records Submitted Medical Record Files are reviewed by CMS MA Organizations with access to the National RADV module in HPMS may review the Submission Tab throughout the submission window period to identify valid or invalid submissions Reasons for an invalid submission: Wrong record/no name Missing signature Name variation Date missing Invalid provider type, lab only, super-bill, non-face to face, SNF Credentials missing Date outside data collection period Provider type on the medical record doesn t match the provider type selected on the Medical Record Coversheet Other A portion of the medical record appears to be missing, cutting and pasting a medical record, or medical record pages don t flow correctly February 13, 2020 CY18 National RADV 43
Receipt and Review of the Medical Records (continued) The medical record coders will review the date (physician/outpatient records) or range of dates (inpatient records) entered on the Medical Record Coversheet The coders will abstract all valid ICD-10-CM codes based on the documentation For example, if the medical record indicates pneumonia and congestive heart failure, they will abstract both diagnoses All coding discrepancies are confirmed using two independent coders February 13, 2020 CY18 National RADV 44
Medical Record Submission Feedback February 13, 2020 CY18 National RADV 45
Medical Record Submission Feedback Feedback on acceptability of submitted medical records and attestations is available within HPMS throughout the submission window period MA Organizations are encouraged to submit early in the National RADV module in order to take advantage of the feedback available in HPMS Submissions with file format or validity issues should be corrected and resubmitted before the submission deadline: June 8, 2020 MA Organizations are encouraged to monitor the Submission Tab in the National RADV module within HPMS in regular intervals to identify submissions that should be corrected and resubmitted. February 13, 2020 CY18 National RADV 46
Medical Record Submission Feedback (continued) Interim Findings Reports: The report will show whether the sampled CMS-HCC has been found, as an exact match Will not detail whether a higher or lower manifestation has been found within the CMS-HCC hierarchy Will not show any additional CMS-HCCs Do not rely solely on the report for medical record validity status HPMS is the definitive source for validity/invalidity status The report will show results for coding steps as of a certain cutoff date February 13, 2020 CY18 National RADV 47
CY18 National RADV Important Reminders and Contact Information February 13, 2020 CY18 National RADV 48
Important Reminders Ensure confidentiality of beneficiary information Do not submit any medical records via email Do not direct providers to send documentation to any NAT18 RADV or HPMS mailbox Do not instruct providers to submit records directly to CMS Compromise of PHI or PII will be reported to the CMS Computer Security Incident Response Team All submissions must comply with requirements defined in the CY18 National RADV Medical Record Submission Instructions February 13, 2020 CY18 National RADV 49
Contact Information HPMS User Access Help Password resets, status on your new account, HPMS login issues, and access to the National RADV module Call CMS Help Desk: 1-800-562-1963 Email: hpms_access@cms.hhs.gov HPMS Help For all other HPMS questions not related to user access email: hpms@cms.hhs.gov CY18 National RADV inquiries For CY18 National RADV questions email: nationalradv@cms.hhs.gov Please do not email PHI or PII to any mailbox February 13, 2020 CY18 National RADV 50
