What We Do
Leprechaun™ helps you manage the risk profile of your Medicare Advantage plan membership to ensure proper payment from Medicare and quality care for your members.
What is HCC Management?
Beginning in 2007, 100% of your payments from CMS is based on the risk profile of your membership as determined by the Hierarchical Condition Category (HCC) codes generated by their encounters with your physicians. Those payment have already been established, based on how completely and accurately coded your members were between July 2005 though June of 2006.
The good news: you have until January 31, 2008 to correct incomplete and inaccurate coding for dates of service in 2006. This is what we call retrospective recovery, and it involves identifying those charts most likely to contain incomplete or inaccurate codes, and performing a chart review.
Of course, you'd like to avoid waiting 12-18 months for correct payment. To do that, you need a prospective program which educates providers about complete and accurate coding practices, ensures that all your current members seen regularly, and quickly establishes the risk profile of new members. A good prospective program gradually reduces the amount of retrospective work you need to do.
The combination of retrospective and prospective activities conducted by your plan adds up to HCC management. And because 100% of your revenue is HCC-dependent, there is no bigger strategic issue facing your plan.
Outsourcing with Leprechaun
Leprechaun simplifies the process of HCC management for your plan. We start by performing a Rapid Opportunity Assessment (ROA). As the name implies, the ROA quickly shows you exactly how much money you are leaving on the table because of incomplete or inaccurate coding.
Here is the difference that one missed code can make:
| Without Leprechaun | With Leprechaun |
| 67-year old dual-eligible male with 3 unique diagnosis codes | The same 67-year old dual-eligible male with 4 unique diagnosis codes |
| In 2005, without Leprechaun, your plan lost: $95.38 per month, or $1,144.56 per year (4.93%) | |
| In 2007, under full risk adjustment, your plan will lose: $190.76 per month or $2,288.28 per year (9.86%) | |
We take data generated by your Medicare Advantage plan and apply our sophisticated predictive modeling tools to identify individual members for which coding is inaccurate or incomplete (resulting in lower payments than those to which you are entitled by Medicare's own rules). This processing is supported and managed entirely by Leprechaun at our highly secure data center, meaning no additional burden on your internal IT systems.
When the ROA is completed, we share with you the dollar value that incomplete and inaccurate coding represents for your plan, based on both our model and the accuracy of its predictions. (Please contact us if you would like a sample of what an ROA report looks like.)
At that point, you can choose one of three options:
Option 1: Do Nothing
Plans which choose this course of action face an uphill climb to provide the same level of service in the face of increasing costs and declining revenue. We don't recommend it.
Option 2: Leprechaun-Managed Chart Review
At the heart of Leprechaun's business is our ability to identify the most important charts to review for accuracy and completeness. One way to do that is by letting Leprechaun take all the worries and hassles off your plate.
To ensure that retrospective coding inaccuracies are corrected, we deploy and manage teams of trained nurses and certified coders who use Leprechaun data outputs to engage in highly focused chart review at your provider offices. We work carefully with you throughout this entire process to ensure minimal disruption of these offices, and maximum accountability for our efforts.
Even more importantly, we help you get coding right prospectively. No MCO wants to go to CMS year after year with retroactive appeals for additional revenue. Not only does it strain the sensitive relationship you have with CMS, but getting to that point is a time consuming effort. To that end, Leprechaun gives you the tools and educational programs you need so that you can prospectively work with your providers to ensure that your members are appropriately evaluated and coded for every time they visit their provider.
Option 3: Self-managed Chart Review
Alternatively, you can use your own personnel to review charts which Leprechaun has identified as most likely to have inaccurate or incomplete coding. Leprechaun provides Web-based access to our analysis of your data showing which offices to visit and which charts to pull.
We provide extensive training and our Windows-based Chart Assistant to your review personnel to ensure that you get the results you expect, and we give you Web-based management reporting to track your progress. You'll be able to see the detailed economic results of your review program as incomplete or inaccurate data is discovered by your reviewers. Plus, we provide the data you need to conduct effective prospective programs with your provider network. And of course, we regularly update our analysis with data you periodically provide.
Best of all, we support you every step of the way. Your success is our success.
Leprechaun: Your Competitive Edge
There is no doubt that successful Medicare Advantage plans will be those who take charge of HCC management to obtain an accurate risk assessment of their membership. Leprechaun is the leader in helping plans achieve this accuracy by identifying the most likely cases of incomplete or inaccurate HCC information.
Whether you choose to let Leprechaun do all the work, or manage it yourself, you need to take to take the first step and schedule a Rapid Opportunity Assessment.
For more information or to schedule a demonstration, please contact Charles Gaughan at (817) 231-7060.
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