PROGRESS NOTES: CMS Final Reconciliation Delayed

PROGRESS NOTES: CMS Final Reconciliation Delayed

By Richard Schamp, MD, CEO

PACE organizations are accustomed to receiving final reconciliation of the prior year’s Part C and Part D payments in July.  This reconciliation is reflected in the Monthly Membership Report (MMR) and typically includes a positive true-up payment, especially if retrospective reviews were done in timely fashion.  However, this year the PY2016 reconciliation is delayed until October, as CMS communicated during their April CMS Risk Adjustment EDS & RAPS User Group presentation. The delay is due to the Encounter Data reporting extension for Medicare Advantage Organizations, but impacts PACE as well.

Results of the 2017 mid-year model run should be available with the August Monthly Membership Reports at the end of this month.

Richard Schamp, MD
Chief Executive Officer

Capstone continues growth beyond PACE

CMS and other payers continue to expand the use of value-based payment models, which are often based on some form of risk-adjustment. Accordingly, more physician groups are realizing they need to understand the implications of these alternative payment models on their own documentation and coding practices. I recently heard the assertion that in the future, providers will need to demonstrate a new competency to their employers:  clinical documentation excellence. This burgeoning requirement is already acutely realized in Accountable Care Organizations, Medicare Shared Savings Programs and other care models that depend upon complete and accurate recording and coding of diagnoses, besides procedures.

We are pleased to provide training and auditing to physician groups in several states.  Some groups are already in alternative payment models while others are getting their toes in the water, anticipating future needs.  If your parent or sister organization is part of an ACO or other alternative payment model besides PACE, we would be happy to start a conversation about how to prepare their providers for healthcare payment realities of the future.

Client Success System

From our roots in working in PACE organizations ourselves, our Leadership Team understands the value of Quality Assurance and Process Improvement (QAPI).  We’ve been busy applying Process Improvement to our internal processes and have evolved our client support model, which is now known as our Client Success System.  If you are a Capstone client, you’ll be hearing more about this in the coming months, and we trust you’ll find it valuable as we continue to partner for success.

All good wishes for a safe and enjoyable summer!