medicare advantage

Medicare Star Rating Improvement

Medicare Advantage plans depend heavily on their Star rating for their total compensation.  While many of the metrics are within a plan’s control, more than a half of the Part C rating is based on HEDIS which reflects provider activities.  Payers that need to improve their rating must engage their providers if they are to benefit from a sustained improvement in HEDIS metrics.

In 2015, the threshold for a bonus payment from CMS will rise to 4 stars to get a 5% bonus. However, if you are below this threshold, your bonus will be zero. Moreover, Star ratings will also affect your rebate payment and how you can market your plan. If you are going to be in the Medicare Advantage business, you must have a plan to improve and maintain your rating.

Focus on Making a Difference

It is critical that you give your providers actionable information on their activities that drive your HEDIS metrics and give them a means to securely communicate back to you. Your MA compensation depends on what your providers do since HEDIS metrics in domain 1 and 2 can account for more than half of your part C rating. Provider metrics account for approximately two-thirds of the 36 Part C metrics, and 73 percent of the total weight of a Part C Star Rating score. Research has found that provider metrics account for approximately 90 percent of the total variation in Star Rating scores.


However, those are the components that are least in your control since the metrics reflect provider behavior. Too often, health plans focus on informing the member rather than engaging and influencing the providers.

Continuous Improvement

The Provider Engagement for Stars Module for Avior BenchMark is a Software-as-a-Service (SaaS) platform that allows you to quickly and efficiently manage the engagement of your providers on their HEDIS metrics for your plan. We import HEDIS metrics by provider and member from your existing system then our platform identifies the gaps in care for each provider, giving them easy-to-view reports and tools by member. Rather than relying on complex reports to communicate with providers, the system breaks each care metric into a task. It is important that the task be granular; each task address a provider about a specific patient and procedure. It must also be actionable. Providers give on-line feedback on each task for a closed loop process that optimizes results. This continuous improvement process helps improve and protect your rating by addressing all gaps in care. You use our reports to validate that this new data flows through to your HEDIS reports.

Gathering Supplemental Data

Avior's analysis of HEDIS data indicates that at least 7% of HEDIS tasks cannot be counted because of coding issues. In addition, MA plans may not have complete information about a member's claims history such as prior procedures or conditions that would exclude them from a metric. MA plans have used methods like site visits and medical records retrieval services to gather supplemental data. However, these are expensive and time consuming manual processes. Avior BenchMark automates the complex interactions between plans and their providers. This automation drives out cost while helping plans get their QBP. We call the workflow to gather supplemental HEDIS data the Virtual Chart Review.


Like traditional methods, the Virtual Chart Review gathers supplemental data in accordance with NCQA and CMS requirements. Since every task is tracked at every step in the process, audit capabilities are built in to the system.

GAP in Care Checklist

Obviously, there will be gaps in care which must be completed. Avior BenchMark supports the creation of job aids such as a gap in care checklist. This is a report that lists all open tasks for a given member and can show information such as the right codes for the procedure or other instructions to help get the right information coded. This report can be stored in electronically in the HER to be used at the time of care. This complements the Virtual Chart Review and helps provide a complete solution to improving HEDIS metrics and your Star rating.

Proven Platform for Provider Engagement

Avior's BenchMark platform is designed to manage large scale programs in dealing with risk and compliance issues for large groups of third parties, like provider networks. Automating routine tasks allows you to focus resources on finding and fixing problems. We have proven this approach with our ICD-10 Provider Readiness Solution Pack in the largest payer environments. Our secure on-line approach gives the provider all of the information they need to be successful. Most importantly, the platform allows for feedback from the provider so you can monitor your progress toward a higher rating.

 

Video Q&A on Provider Engagement and Stars:

 

 

 

 

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Watch the Webinar

5 Lessons from the Latest CMS Star Rating Data

In October, CMS released the Star Ratings which includes an enormous amount of data about the performance of all MA contracts. Avior has combined this data with enrollment data and done an extensive analysis. We want to share 5 critical lessons from this analysis:

  • Why one metric can tell you how well your providers can code
  • Which key metrics can be your canary in the coal mine
  • What enrollment trends tell us about how consumers view quality
  • How much of your rating is based on your location
  • How to compare your results to your competitors

These insights are important to anyone responsible for managing a plan's MA star rating. Join us for this 30 minute overview of our findings.

 

Did you miss our most recent webinars on Using Provider Engagement to Improve Your Star Rating? Watch the replay here.

Get our Stars White Paper

This paper explains the importance of automated provider engagement to improve your Medicare Advantage Star Rating and gives 10 criteria for a successful program.

Click to download

Get the Star Rating Datasheet