A Lost Opportunity

Beam Partners specializes in helping health plans recover additional unpaid Medicare premium. Our staff utilizes customized software combining the health plan's medical claims and pharmacy data to identify the medical records that qualify for additional review and possible submission to CMS with a request for appropriate payment adding revenue to your bottom line.

Health plans participating in the Medicare Advantage program operate under a diagnosis-based risk adjustment system that pays higher monthly capitation rates for enrollees with higher morbidity levels. Diagnosis codes extracted from medical claims are submitted to CMS. CMS uses these diagnoses to assign enrollees to disease categories. The problem exists that medical claims are often an inadequate representation of enrollees' true morbidity.

• Only a fraction of the diseases and conditions documented in the medical record
• ever make it to the claim form or record submitted to the health plan
• Inadequate claims information is often the case for new enrollees
• Inadequate diagnosis coding is common because diagnosis codes rarely factor into the claims adjudication process

Every disease not submitted to CMS that is included in the CMS-HCC model represents lost revenue to the health plan. This lost revenue is most acute for those patients who are laboring under the burden of multiple comorbidities and are likely to require a disproportionate share of the health plan’s resources.

Solution and Approach

Solution and Approach
Our approach uses analysis of medical and prescription drug data to identify relevant diagnosis that are potential markers for a diagnosis that CMS would recognize for additional payment. This analysis considers prior diagnosis, prior year HCC's, and expected comorbidities. These "suspect" diagnoses are identified for review and confirmation by a certified coder.

Upon confirmation of the suspected diagnosis, the additional diagnoses are submitted to CMS for inclusion in the HCC calculation, driving payment adjustments in your favor.

Beam utilizes a team steered by a project manager, nurses, and code reviewers to assess data and medical charts. Our staff works closely with the health plan's staff to ensure cooperation with the providers and to maximize the recovery of the lost premium.

Opportunities
Prior to a detailed review of claims data, our team can estimate potential financial opportunity. Our prior experience indicates an estimated recovery of $3 million for every 10,000 members in the Medicare plan. For 25,000 members this is approximately $7.5 million.

Costs 
Beam will provide an estimate on all project and software costs associated with the project. Costs and expenses are billed and payable when invoiced.

Begin Now
The deadline is January 31, 2007 for 2005 claims. The earlier the plan begins this review, the higher rate of recovery is possible.

Contact Beam Partners for a review and estimate of your potential recovery costs. The difference could mean literally millions of dollars in your favor.