3M℠ Risk Optimization Services

Under the Affordable Care Act (ACA), the payment transfer process calls for funds to be transferred from plans with lower-risk enrollees to plans with higher-risk enrollees to protect against adverse selection. This process applies to non-grandfathered individual and small group plans inside and outside the health insurance exchanges.

As a result, plans must ensure that the risk of their exchange-eligible population is accurately captured under the hierarchical condition categories (HCC) model, HHS’s required risk-adjustment methodology, so they can minimize the possibility of leaving money on the table at the year-end payment transfer reconciliation.

This process can be problematic because providers may not be coding diagnoses as accurately as possible, and certain cases may not trigger a condition under the HCC model. For example, patients with chronic conditions who do not visit their doctors would not have sufficient experience to trigger an HCC assignment. Thus, it falls to the plans to make sure their members’ risk is accurately reflected under the HCC model.

3M Risk Optimization Services give plans the analytics to perform ongoing identification and management of both network and member opportunities. This allows them to be accurately and completely reimbursed at the time of the payment transfer reconciliation.

Through the 3M member-level grouping process, which simulates the HCC model, the analytics and reports show:
 

• Year-over-year HCC trend for the group’s members, split by demographic and diagnosis components
• Members who had an HCC in the prior year, but who do not have one in the current period
• What the HCC score would be if members who previously had HCC assignments were coded to maintain them year over year; this shows the potential impact improved coding could have on overall population risk score, which ultimately affects year-end payment transfer amounts
• The average missing score for each member segment, which also shows the potential impact of improved coding

• Health plan executives who need to understand the true illness burden of their member population to inform strategic decisions, such as which markets they want to be in, and to determine whether they are reimbursed accurately under the ACA
• Network managers who need access to information about provider diagnosis and coding practices to inform decisions regarding programs that educate and incentivize providers
• Provider relations staff who need reports and data to inform providers of their opportunities to improve their diagnosis coding practices
• Care managers who need lists of patients—with either known or unknown diagnoses—who are likely to have chronic conditions and need to see their primary care provider (PCP)

Member-level reports inform provider and patient outreach efforts; identify members who have had gaps in coding; and pinpoint patients who appear to have an underlying illness burden not captured by the HCCs.

Network-level reports identify coding variation and deficiencies from a network perspective; highlight network performance trends over time and comparisons across the network; and examine coding variations at the individual physician, practice or ACO levels.