PORTLAND, Ore.— It’s not common for health plans competing in the same market space to work together, but this fall that’s precisely what Regence BlueCross BlueShield of Oregon and Moda Health did when they had RISE present an in-depth workshop in downtown Portland for coders and providers on best practices (that were not payer-specific) for chart documentation, coding, and billing. This unique learning opportunity led to a collaborative work group that addressed populations at risk, regardless of the insurer. And both health plans and attendees told RISE they’d recommend other payers give this unique learning opportunity a try.
The opportunity to work together and sponsor the educational program, even though the two health plans are in the same market and compete for the same membership, was unprecedented, says Jennifer Ellis, CPC, CRC, Medicare provider performance manager for Regence.
But it left a great impression on the provider groups in attendance because it showed the health plans are acting in the best interest of their members/patients and providers.
Indeed, Ellis says that when you think about risk adjustment and quality, at the center of it is the member/patient. “I think we can work together and collaborate in some spaces to bring in education so we can achieve the ultimate goal of accuracy and coding, which reflects an accurate RAF score,” she says. “If you focus on accuracy and capturing the right conditions at the highest specificity then the RAF score will take care of itself.”
Although the model for the training workshop was unusual, it was beneficial, according to Mark Danburg-Wyld, an actuary for Moda Health Plan, which served as the host site for the program. “I think it can make sense for payers who are otherwise competitors to collaborate in this way,” he says.
For Brianne Eckenrodt Page, the head of Moda’s coding team, the eight-hour class was especially helpful because her entire coding team heard the same information. The instructor of the workshop, Donna Malone, CPC, CRC and ICD-10 trained, validated Page’s rationale for HCC coding practices in many cases. And Page appreciated the perspective of Malone, senior manager, Enterprise Risk Adjustment, HCC Coding and Quality Assurance for the five-star Tufts Health Plan in Massachusetts.
“It was helpful to hear from the payer’s perspective from someone who is also a coder,” Page says. “She had a lot of experience to draw from. I got a lot out of it.”
Megan R. Lent, MIS, the risk adjustment process manager for Medicare Advantage for Moda, also had high praise for the program. Lent says she learned a lot and appreciated that Malone walked through risk adjustment and coding strategies using real-world applications and case studies.
Rachel Mueller, CPC, CRC, a coder for the Oregon Medical Group who attended the program on behalf of her provider organization, was also a fan. “I’ve attended a lot of coder programs and Donna was an exceptional presenter. She is well-spoken, knowledgeable, and kept the audience involved,” Mueller says. “I was pleased to be included. I highly recommend it.”
In addition to the top-notch content, Mueller said she also enjoyed the fact that there was a mix of attendees, including coders, CDI specialists and physicians, because it allowed for feedback from payers, coders, and clinicians.
Lynn Stachlowski, CPC, CRC, CPC-I, CPEDC , a coding & documentation specialist with Adventist Health, says it may be unusual for competing health plans to work together, but they both aim to reach the same business in a small market pool. It behooves them to work together because in most cases the providers will see the same patients regardless of which health plan the patients belong to, Stachlowski says. The training is important to ensure that the providers are capturing the appropriate codes before claims submission.
“It took a lot of guts for the two insurers to do that. It took someone who was thinking outside the box to put together a workshop sponsored by two different insurance companies. And I think it was very successful,” Stachlowski says.
Jackie Thompson Moore, care coordinator for Cascade Physicians, agreed. “It was great that a non-profit and a for-profit put together something that would help not just providers, but the whole team,” Thompson Moore says. “The speaker was phenomenal. She was so informative. A lot of the things she explained to providers was that you have already done the work so why does your assessment not support your work? She gave some great examples of how doctors miss these things.”
Malone also taught the workshop in a way that made it clear that regardless of whether you were submitting claims to Moda or Regence, the coding and billing practice was still the same, according to Thompson Moore. “She provided a great perspective on the payer side. It was very interactive, and it helped because it allowed everyone in the room to connect the dots,” Thompson Moore says.
“Donna’s deep experience in coding and documentation extends beyond just Medicare health plans,” says Kevin Mowll, executive director of the RISE Association and RISE Institute. “She directly trains providers on all lines of business. Donna has a handle on not only CMS HCC coding, but also on the HHS program and Medicaid. Her expertise is shared in these training programs and everyone walks away enriched by her skilled training.”
To learn more about RISE onsite training programs, click here.