Medicaid Encounter Data Workshop

Compliance Activities - Summary
Reports and Analyses

  • To ensure accuracy of encounter data, monthly validation and volume reports are posted to the Health Commerce System(HCS)to assist managed care plans in identifying potential reporting issues.
  • In the future, reports will highlight areas where your reporting is outside the normal range relative to other managed long term care plans.
  • Reports located via MEDS Home Page on HCS https://commerce.health.state.ny.us/hcsportal/hcs_home.portal
  • MEDS Compliance will utilize these reports as well as internal reports as a basis to evaluate compliance with reporting standards and reach out to those plans identified to confirm reporting is accurate/complete as submitted or assist in resolving issues.

FOCUS OF DATA VALIDATION REPORTS

  • Allow health plans to compare/assess reported encounter data in these areas with that of other managed long term care plans:
Acute Care/ Other Inpatient Care Prescriptions
Home Health Care Nursing Facility
Other MLTC Personal Care
  • Validation report highlights:
    • Member Months
    • Units and Unit Cost
    • Sum & Total Paid Amount of encounters on file
    • Paid Amounts Per Member Per Months (PMPM)
    • Medicare Paid Amount (PACE and MAP)

Service Classification

Medicaid Managed Long Term Care Encounter Data Utilization and Cost Report         Page 1 of 1

Acute Care/Other PACE/MAP
Inpatient Care (Medical/Surgical, Psychiatric, Acute Detoxification, Substance Abuse, Newborn, Maternity)
Emergency Room Visits
Prenatal and Postpartum Care Services
Family Planning Visits
Primary Care
Physician Specialist
Ambulatory Surgery
Diagnostic Testing, Laboratory and X-Ray
Outpatient Drug and Alcohol Services
Outpatient Mental Health Services
Outpatient Pharmacy (Service line revenue code reporting)
Renal Dialysis
Other Professional, Medical Services
Home Health Care
Medical Social Services
Nursing
Occupational Therapy
Physical Therapy
Respiratory Therapy
Speech Therapy
Social and Environmental Supports
Nutrition
Nursing Facility
Nursing Facility Care (Units are days)
Other MLTC Services
Dental Care
Durable Medical Equipment
Personal Emergency Response System Emergency Transportation (PACE/MAP) Non-Emergency Transportation
Audiology
Podiatry
Physical Medicine I Rehab
Vision Care
Social Day Care
Adult Day Health Care
Home Delivered Meals
Personal Care
Paraprofessional Services Level 1:Homemaker/Housekeeper
Paraprofessional Services Level 2:Personal Care
Paraprofessional Services Level 3:Home Health Care Aide
Prescriptions and Refills
NDC Scripts & Refills (PACE/MAP)
Column Name Description
Plan Name Health Plan Name
Plan Type Type of health plan: MLTC, PACE or MAP
Service Class One of six aggregate groupings of service classifications (Acute Care/Other; Home Health Care; Other MLTC Services; Nursing Facility; Personal Care; and Prescriptions. Not all service classifications apply to all plan types.
Paid Member Months Number of member months during the service period with paid capitation dollars.
Unique Service Lines Number of unique service lines reported in the category. For Nursing Facility lines are events, for Prescriptions lines are scripts nad refills dispensed.
Paid Amount Sum of the raw reported paid amount by the health plan for the service category.
Pct Admin Denied Number of service lines reported by the health plan as "Administratively Denied". (Number of Lines Submitted as Administratively Denied / Total Number of Lines Submitted) ∗ 100
Lines Denied Submitted with Paid Amt Number of service lines reported by the health plan as "Administratively Denied" but reflecting a paid amount greater than zero. These lines need to be corrected b the health plan through the adjustment/void process as soon as possible for accurate data reporting.
Pct Lines Submitted Zero Number of services lines reported by the health plan as paid, but containing zero paid amount dollars. (Number of Lines Submitted with Zero Paid Amount / Number of Paid Services Lines) ∗ 100. Accuracy in encounter data cost reporting is important for the annual risk ratio development process.
PMPM Cost The Per Member Per Month average cost (Paid Amount / Member Months).
Units or Days Sum of the raw reported units by the health plan for the service category. For Nursing Facility, the sum is unique days per recipient. For Prescriptions, units are the sum of quantity dispensed.
Unites are a very important piece of information reported on the encounter record that quantifies the unit of measurement for each of the service areas. Depending on the type of service, the unit of measurement will change. Plans should take into account the unit of measurement ofr each service when choosing CPT/HCPCS codes and reporting the number of units for each encounter record.
Per Unit Cost The Per Unit average cost (Sum of Paid Amount / Sum of Units or Days).

Managed Long Term Care
Medicaid
Encounter Data Validation
1/1/2012 Through 12/31/2012
Service Class Plan Name Plan
Type		 Member
Months		 Service
Lines		 Pct Lines
Submitted
Zero		 Pct
Admin
Denied		 Lines
Denied
Submitted
w Paid
Amount		 Paid
Amount
MMC		 Paid
Amount
Medicare		 PMPM
Cost
MMC		 PMPM
Cost
Medicare		 Units /
Days		 Per
Unit
Cost
MMC		 Per
Unit
Cost
Medicare
Acute Care/Other
ARCHCARE SENIOR LIFE PACE 2,693 32,811 62.40 5.72 0 $1,072,319.61 $0.00 $398.19 $0.00 16,177 $66.29 $0.00
CENTERLIGHT HEALTHCARE PACE PACE 38,145 375,207 57.83 0.34 0 $12,865,346.42 $4,605,190.67 $337.27 $120.73 204,080 $63.04 $22.57
CHS BUFFALO PACE - LIFE PACE 1,240 11,895 45.75 8.45 0 $271,091.34 $0.00 $218.62 $0.00 7,878 $34.41 $0.00
COMPLETE SENIOR CARE PACE 506 2,018 21.37 10.26 0 $94,343.10 $0.00 $186.45 $0.00 1,526 $61.82 $0.00
INDEP LIVING FOR SENIORS PACE 4,018 51,055 75.25 2.54 0 $1,452,539.57 $13,657.44 $361.51 $3.40 40,841 $35.57 $0.33
PACE CNY PACE 5,451 89,946 74.60 0.00 0 $2,636,493.27 $0.00 $483.67 $0.00 27,129 $97.18 $0.00
SENIOR CARE CONNECTION PACE 1,542 15,411 83.50 0.00 0 $201,610.12 $79,935.60 $130.75 $51.84 2,550 $79.06 $31.35
TOTAL SENIOR CARE PACE 1,007 14,850 52.70 4.10 0 $406,678.43 $0.00 $403.85 $0.00 7,917 $51.37 $0.00
AMERIGROUP MEDICAID ADVANTAGE MAP 122 2,161 99.71 5.18 0 $339.55 $0.00 $2.78 $0.00 8 $42.44 $0.00
ELDERPLAN MAP 8,162 73,127 77.04 0.00 0 $547,225.00 $1,327,088.53 $67.05 $162.59 30,001 $18.24 $44.23
FIDELIS CARE OF NY MAP 1,331 23,941 39.37 6.84 0 $1,382,358.02 $2,547.10 $1,038.59 $1.91 14,137 $97.78 $0.18
GUILDNET ADVANTAGE PLUS MAP 4,554 58,248 51.87 5.03 3 $1,807,974.91 $2,450,602.63 $397.01 $538.12 82,074 $22.03 $29.86
HEALTHFIRST COMPLETE CARE MAP 2,645 29,942 99.26 13.21 0 $14,532.92 $49.20 $5.49 $0.02 3,713 $3.91 $0.01
HIP OF GREATER NY MAP 4,286 48,178 54.80 3.84 633 $3,528,308.18 $1,765.87 $823.22 $0.41 820,471 $4.30 $0.00
SENIOR WHOLE HEALTH ADV PLUS MAP 3,439 51,843 40.41 0.00 0 $2,303,846.38 $0.00 $669.92 $0.00 46,751 $49.28 $0.00
VNS CHOICE ADVANTAGE PLUS MAP 1,150 34,113 99.95 0.04 0 $1,059.77 $494.30 $0.92 $0.43 886 $1.20 $0.56
WELLCARE ADVANTAGE PLUS MAP 599 78 43.59 0.00 0 $774.80 $6,034.39 $1.29 $10.07 49 $15.81 $123.15
SERVICE CLASS TOTAL 80,890 914,824 63.24 1.83 636 $28,586,841.39 $8,487,365.73 $353.40 $104.92 1,306,188 $21.89 $6.50

Encounter Data Received Through: August 2013
Report Date: 09/24/2013

FOCUS OF SUBMISSION VOLUME
REPORTS

  • Used to identify variances in reporting and potential issues in submission of data.
    • Unique Enrollees
    • Encounters Per Person
    • Encounters Submitted
  • Submission Volume compliance efforts will focus on a comparison of the plans reporting for CY 2013.
  • Should issues be identified, MEDS Compliance Unit will contact plan for confirmation and or explanation of data.
  • Reporting issues that are not properly addressed may result in issuance of Statement of Deficiency.

MEDS to MMCOR

Overview

  • PMPM cost data comparisons are conducted on raw encounter cost data, shadow priced cost data and reported MMCOR costs
  • Performed on a calendar year basis
  • For SFY 12-13, shadow pricing ratio had to fall within the range of 0.69-1.02
  • 14 of 22 Plans reported sufficient data to be included in the SFY 12-13 rates
  • PC/HHC, Nursing Facility, and Other categories are reviewed

Plans Included in SFY 12-13 Model
Development (CY 2010 data)

  • Amerigroup New York, LLC
  • CCM Select
  • Comprehensive Care Management
  • Eddy Senior Care
  • Fidelis Care at Home
  • GuildNet, Inc.
  • HHH Choices Health Plan
  • HomeFirst, Inc.
  • Independence Care System
  • Independent Living for Seniors
  • Senior Health Partners
  • Senior Network Health
  • Total Aging in Place Program
  • VNS Choice

MEDS to MMCOR - April/July 2012
Rates

Health Plan Name Type Raw Total Shadow Total
Eddy Senior Care PACE 0.92 1.02
Senior Network Health MLTC 0.87 1.01
Comprehensive Care Management PACE 1.02 1.00
Senior Health Partners MLTC 0.97 0.97
Fidelis Care at Home MLTC 0.90 0.97
GuildNet, Inc. MLTC 0.94 0.95
CCM Select MLTC 0.93 0.92
HomeFirst, Inc. MLTC 0.89 0.90
Amerigroup New York, LLC MLTC 0.89 0.90
HHH Choices Health Plan MLTC 0.88 0.89
VNS Choice MLTC 0.83 0.84
Total Aging in Place Program MLTC 0.73 0.76
Independent Living for Seniors (ILS) PACE 0.73 0.73
Independance Care System MLTC 0.69 0.69
Total Senior Care PACE 0.39 0.43
CHS Buffalo LIFE PACE 0.27 0.41
PACE CNY PACE 0.08 0.29
Wellcare Advocate MLTC 0.26 0.27
Archcare Senior Life PACE 0.24 0.24
Elderserve MLTC 0.21 0.21
Elant Choice MLTC 0.11 0.18
GRAND TOTAL 0.86 0.86

Accuracy

  • What can plans do to improve accuracy?
    • Check units
    • Check price
    • Check specialty code

QUESTIONS?

MEDS RESOURCES