The high cost of doing business has been met with inadequate increases in reimbursement by CMS and these issues have created an environment of financial uncertainty for Medicare Advantage (MA) plans.

There is a solution, our MA Plan Support platform can help you reduce Total Cost of Care, improve provider utilization, the ability to act upon information immediately, and help your providers create accurate documentation that supports a patient’s diagnosis and satisfies potential Quality Care and CMS audits. In addition, create new Medicare billings for your provider clinics and increase billing encounters and reimbursement that meet the expectations of your plan providers.

Many MA plan executives boast about their robust risk adjustment, cost of care, abstract coding teams, care coordination, and provider education. Unfortunately, they are still apathetic about action needed because up until now, fully meeting requirements has not amounted to any significant increase in revenue. This has now changed.

So, now MA plan executives need a new and significant value to show their Board and providers. Our MA Plan Support platform is the answer.

We offer a comprehensive suite of services:

• Medicare CCM Program Optimization
• RAF Compliance Optimization
• Patient Outreach Optimization

See below for the important details on each.

Most MA Plans are Not Optimized for the Medicare CCM Program

CMS has a program that you might not think of as a core mission for your MA plan. But what if activities you already perform could generate new Medicare Revenues, both for your MA plan directly, and for your providers?

Optimization for the Medicare CCM Program is Natural

CMS offers the Medicare CCM Program that pay above and beyond office visit based chronic care.  MA plans who think outside the box should be able to easily extend care coordination activities to reimbursable monthly Chronic Care tele-health activity.

It sounds simple, and natural.  After all, everyone cares for chronic patients.  But most provider groups don't have the resources to take advantage of this important Medicare program that reduces costs, generates revenue, and improves patient care.

The Medicare CCM Program is Lucrative

How lucrative? We will do the math for you.

MA-employed nursing staff can generate new revenue that range from $56 to $120 per patient per month, shareable between your MA plan and providers.

We will help figure out what your opportunity could be. We analyze your providers against a series of CPT Codes with reimbursement averaging around $80 per patient per month.  And we pair that with data on each TIN's top 3 Chronic Conditions by patient volume and project the gaps.

We will analyze this impact on you and your first 5 provider TINs at no cost to you.  We use CMS-Public data for this analysis, so there is no effort required by you or your provider TINs.

How We Help You Generate Medicare CCM Program Revenue

• Evaluate existing TIN-level CCM activity.
• Predict incremental physician-level CCM revenues.
• Create an MA Plan-level CCM program.
• Technology for high volume CCM program efficiencies.
• Predict revenue for your MA plan.
• Operational and strategic CCM program support.

The Entrepreneurial MA Plan

Your MA Plan can create a new business, as a virtual CCM vendor to your provider TINs and clinics.

Why Set Up as a CCM Vendor?

Your providers could (and some will) contract with outside organizations who sell Pop-Health / CCM services.  We know this because we are one of those organizations ourselves.  They (we) charge a per-patient-per month fee in exchange for conducting tele-health Care Management visits with qualifying patients.

Those Care Management "calls" can overlap with your own care coordination mission and create confusion among patients.  Would it be better for your own staff to be making these calls? One big benefit is that under Medicare rules, you can get paid for it.  And with your close relationships with your provider clinics, you are in the position to do a better, more cost-effective job of it.

What Do You Need to Combine Care Management with Care Coordination?

IT is like any other business.  You will need a template for a contract / arrangement with your clinics to provide this service.  You will need software that manages Medicare compliance and supports high-volume tele-health scheduling.  And you will need a library of templates for care plans, patient education, and patient consent documentation.

Beyond that, you can leverage existing capabilities, in your nursing care coordination staff, and clinical data integration with TIN EHR / Billing systems.  Our platforms provide all of this and more.  

Provide Patient-Level Nursing Staff to Your Provider TINs and Clinics

Sometimes, the biggest obstacle is just getting started.  Who will do the initial stages, until your volume hits the level where full-time staff is profitable?

The platform provides nursing staff on a per-patient (or even on a per-call) basis.  The cost of these staffing arrangements comes out of clinic billings, so there is little-or-no out of pocket startup for clinical staff.

How Your MA Plan Can Become a Medicare CCM Program Vendor

Software

Our Provider Partner will license (and even white-label) their CCM Software suite to you.  Their software suite is built to create staffing efficiency.  They integrate with clinic EHR and pass billing data to clinic practice management systems.  And their tele-health tools schedule and make phone calls, while tracking nurse time and documentation that Medicare requires for billing.

Further, their software comes complete with configurable care management templates and patient education materials that your nurses will need.

Contracts

Sometimes the biggest speed bump is in drafting the contracts, proposals, and marketing materials that educate and commit clients.  The platform comes complete with the templates that you can use as-is or modify to fit your unique offering configuration.

Processes

There are two dimensions to the Medicare CCM Program.  One dimension (the obvious one) involves certified healthcare professionals interacting with consented patients according to a physician-approved care plan.  In this dimension, all activity is paid for under Medicare.

But there is a second dimension, that often gets overlooked and becomes a big obstacle to a rapid ramp-up.  That dimension involves analyzing your existing patient population and reaching out to them and is pre-funding.  Patients need to understand that they have the option to work with their own dedicated nurse every month, at no cost to themselves.  We support this need with outreach tools that help your team efficiently educate patients and get them enrolled into the "for-pay" component of your offering.

For your MA plans care coordination activity is a natural patient outreach, giving you a huge advantage in achieving high penetration into your chronic condition population.

Staffing

The platform contract will enable - but not require - you to tap into knowledgeable and certified nursing staff.  We call it demand-based staffing that helps kick-start your operation.

Startup Strategy

Think of the platform as something of a "franchise" partner.  Our Provider Partner has already developed the software, templates, and processes that get you a quick start.

 Why CCM is Mission Critical for MA Plans

• CMS estimates that their Medicare CCM Program reduces Medicare cost by $74 PMPM.
• CCM and MA plan overlap in mission-critical areas.
• Chronic condition-based quality.

Where clinical Quality Measures reference chronic conditions, the presence of a Pop-Health /CCM program goes far in sustaining visibility into chronic patients.  And visibility is a first step in managing quality.

Chronic Condition-Based Cost

Cost measures are completely based on Medicare patients.  This makes the Medicare CCM Program particularly powerful in the ability to influence utilization of expensive services, by pre-empting the need with ongoing clinical care.

Care Coordination

Care coordination and care management involve both clinical staff interacting with active Medicare patients.  The goal of both is to prevent the need for expensive services. The difference is that you can get paid for CCM.

Physician / Clinic Relationship Management

Imagine a scenario where your activities generate new revenue for your provider population - daily.  In some cases, you enable those revenues in ways the physicians cannot.  Might that improve physician recruitment and retention?

A New Approach to Risk Adjustment: How Closing Care Gaps Supports Payers' Bottom Line

MA plans face a number of challenges in their risk adjustment programs, from data quality and availability to compliance issues and the complex, time-consuming task of analyzing retrospective data to calculate risk.

While retrospective review is a key part of risk adjustment, your providers will benefit from emphasizing prospective risk adjustment as part of a holistic strategy. The platform’s strategies will streamline care gap closures, reduce administrative burdens, and drive cost savings for your MA plan.

Benefits include:

• Using prospective risk adjustment to make better predictions.
• Technology that proactively identifies care gaps.
• Integration that enables more efficient care gap closures.

CMS Final Rules

CMS’s Final Rules dictate that MA plans must meet Risk Adjustment Factor (RAF) compliance requirement benchmarks and targets to qualify for higher reimbursement.

CMS’s Risk Adjustment Data Validation (RADV) and Transaction Coding of Diagnoses Final Rules, and the National Quality Strategy (NQS) are in effect. These have and will continue to create lower reimbursement and a significantly higher risk of an audit.  In addition, The Transactional Coding of Diagnoses to support billing in a fee-for-service environment is NOT adequate to meet VBC program care requirements.

What Your Providers Need

Your plan providers require a tool that empowers them with instant access to the information and data they need to manage and code each patient’s specific diagnoses – as well as create the documentation that supports the coding.

MA plans need a professional service that delivers results which achieve improved compliance, patient RAF Scores, patient attribution, increased billing encounters and reimbursement, enhanced clinical support, outcomes, patient satisfaction, and cost reduction.

Your MA plan is paid based on patient RAF Scores. It’s a fact that physicians struggle with having enough time to complete MA requirements related to the redocumentation of diagnoses. This can negatively impact the accuracy of patient RAF Scores.

To drive higher reimbursement, plans often seek to identify diagnoses which will result in a higher patient RAF Scores. This requires focus on the coding of a patient’s diagnoses, and not necessarily on how well each condition is being managed. In other words, VBC models have created an overemphasis on coding, instead of on caring.

You use a variety of methods to increase patient RAF Scores. One approach is to review a patient’s medical record, typically after the patient encounter, to identify opportunities for “upcoding” a diagnosis to raise scores. For example, if a diabetes diagnosis can be coded as having neurological manifestations, the risk score will be higher, as will the reimbursement.

Just a quarter-point increase in a patient RAF Score translates into an extra $3,000 per patient per year to your MA plan.

There are a lot of software products coming to and on the market claiming to help identify opportunities to optimize or manage risk, but in reality, they are just a veiled way of upcoding. They do NOT provide the tools at the point of care for the patient; that is, properly manage, evaluate, assess, and treat a patient’s various conditions in accordance with the original intent of VBC: Improved Outcomes Through Better Management of Patient Health.

We will make efficient management of patient care as easy as 1-2-3. And it will Reflect the health status of a patient population accurately and compliantly, which makes it a vital tool for MA plans and their providers.

RAF Compliance Technology

Our MA Plan Support Platform technology provides the top-tier support you and your providers need on VBC reporting and outcomes management. Through EHR forensics, it allows them to view provider level risk scores from the prior and current years as well as the overall average risk score. You and your providers will be able to drill down to the usage of unspecified and unsubmitted coding and all patients associated with a provider.  This will show the dates of a patient's last physical exams, next appointment, number of ER visits, number of diagnoses codes, the number of unspecified as well as unsubmitted coding, and the patients risk score.

Being able to view this information allows you and your providers to identify areas that need further improvement or education and is vital for getting a patient scheduled for Chronic Care Management (CCM) conditions that need to be maintained and documented for improvement of the patient’s accurate risk score.

Under the NQS, VBC, and Standards of Care Guidelines where a medical necessity is found, action must be taken, unless the patient declines the service. Failing to do so can result in the penalty of lower reimbursement. Even if your MA plan and / or providers are doing Annual Wellness Visits (AWVs) and Health Risk Assessments (HRAs) for every patient, your MA plan and / or providers must act on any medical necessities found within those results. And each time a patient encounter is completed, new medical necessity “next steps” must be immediately identified.

Most MA plans and their providers swing & miss on identifying many services that can generate hundreds of thousands of dollars in additional annual revenue with VBC such as Chronic Care Management.

The platform provides electronic beneficiary engagement and completion of the assessments.

Specific types of assessments are sent to an entire patient population throughout the year for completion including Health Risk Assessments, Social Determinants of Health Assessments, and others. They are delivered electronically via email and/or text / SMS and designed to gather relevant health information and engage patients in between visits, as well as obtain updated contact information as part of the process. Then patients can be engaged based on their low, moderate, or elevated risk.

The assessments reflect the health status of patients accurately and compliantly and are helpful at identifying elevated health risks and prompt the patient to come into the office prior to next scheduled visit. Thus, potentially helping to minimize hospital admissions and Urgent Care or ER visits. The patient is also asked to confirm and consent to the provider's review of the assessment results, which will result in a billable E-visit.

They are designed to gather the maximum relevant health information, whether the treatment standard is MIPS, HEDIS, STAR or Quality Care Measures, the platform pivots to those measures.

Patients with High Risk Factors are asked to schedule an appointment with their PCP within the next 7, 30 or 90 days, based on approved protocol. Follow-up actions from here are additional electronic engagement, virtual care, or in-office visits. And this creates immediate revenue and achieves enrollment attribution for patients.

The patient communications are a combination of compliance statements and rewards that creates a 45-65% response rate, while the response rate of all other patient engagement methods is in the low to mid-single digits. The best part, in as little as 30-45 days the platform can significantly improve billing encounters.

Most services are provided at zero up-front cost and are only reimbursed when paid for patient services rendered.

Based on the individual risk level, patients can receive an email or phone call based on their needs and a staff’s direction to facilitate additional electronic services, a virtual appointment, or in-office visit. This could be a scheduling phone line, an email address, or even a link to book their own virtual or live appointment. You and your members decide how you want each category handled.

Managing the Increase in Patient Visits

The first step is to put the right patients in front of appropriate staff / personnel. Physicians are surprised to learn that over 50% of patients can appropriately be handled by another staff / personnel member.

The platform has a national network of PAs, NPs, MAs, etc., that are at your disposal who can help further triage moderate-risk patients into action or support staff/personnel if needed.  And this can be white labeled.

Our MA Plan Support platform is the empowering solution that will ensure you and your plan providers meet all requirements, improve Star Ratings and patient outcomes, reimbursement, and reduce Total Cost of Care and unlock Medicare CCM Program revenue streams. A reasonable analysis and / or set-up fee applies.

We provide the support you need. All our services are tailored to each MA plan and provider clinic's specific needs, which can change from one year to the next. They require very little workload and no additional staffing requirements.

Unlocking Financial Rewards starts with an analysis.  Because to determine the best course of action, we must first find out out exactly where your MA plan and providers are hitting and where you are missing.

Take a few moments to download our supporting materials.

• CMS MLN CCM Booklet (pdf)
• Medicare Chronic Care Management for Seniors article (link).
• CMS Outreach and Education on CCM report (pdf).
• Mathematica 2017 report on CCM (pdf). (This is an important study, but a bit long.  See page 64 for the Bottom Line)
• 2024 CMS RADV Final Rule Changes (pdf).
• CMS Proposes Major Changes to Medicare Advantage HCC Codes in 2024 (pdf).
• Diagnostically Connecting Data and Diagnoses (pdf).

Our Provider Partners are the leading professional service providers and consulting firms that specialize in the processes of RAF Compliance, Medicare CCM Program, and Patient Outreach Optimization for financial ROI.

They support thousands of independent and hospital-based physicians & clinicians, multi-TIN organizations, IPAs, ACOs and APMs and their Member TINs.

They’re specialists that possess knowledgeable teams of people that handle all necessary tasks, provide frequent reporting, and useful analysis.

In a 30-60-minute Zoom call, we will talk more about the Analysis and how we can help your MA plan and provider meet your mission goals, increase reimbursement, and provide you with something you will be proud to show your Board.

Take a moment to download our NCND. Complete and email it to: support@livewellaps.com. Then reserve your Zoom call with us.

1. Click Here to download our Mutual NCND (pdf).  We are NOT data miners. Your info will be kept strictly confidential. We will also be sharing proprietary and confidential information with you on the Zoom call.
2. Click Here to go to our Calendly page to reserve your Zoom call (complete the required fields and when asked “purpose of call,” click: MA Plan Support).