CMS Hierarchical Condition Category Model and HEDIS Quality in Medicare Advantage
This activity will review the basics of the Centers for Medicare and Medicaid Services (CMS) hierarchical condition category (HCC) model within the Medicare Advantage (MA) program. Patients with multiple chronic medical conditions typically have higher costs of care and require more resources. In a typical fee-for-service model there are limited mechanisms to recognize and address these discrepancies. The CMS HCC payment model adjusts reimbursement based on the presence or absence of serious medical conditions such as diabetes or heart failure. Over time, more accurate coding results in more accurate reimbursement.
The Healthcare Effectiveness Data and Information Set (HEDIS) and Star ratings also play a part in the health plan reimbursement for MA members.
This activity is provided by OptumHealth Education.
This activity is supported by OptumCare.
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This activity is designed to meet the educational needs of physicians, coders and other health care professionals who have an interest in health care economics.
At the end of this educational activity, participants should be able to:
- Review information about MA.
- Define why CMS requires health plans to report accurate documentation related to chronic medical conditions for MA members.
- Review how accurate documentation can positively impact Star ratings and quality scores.
- Recall CMS quality measures and their importance.
- Explain how the National Committee for Quality Assurance (NCQA) and HEDIS can help bridge gaps in care.
- Review the HEDIS measure for colorectal cancer screening.
Sarah Chart, RN
Eden Prairie, MN
Rebecca Gleason, RN, CCM
Eden Prairie, MN
Tania M. Miedico, MD
Clinical Performance, OptumCare
Eden Prairie, MN
Disclosures of relevant financial relationships
In accordance with the ACCME Standards for Commercial SupportSM, OptumHealth Education (OHE) requires all those involved in the development of activity content to disclose their relevant financial relationships. An individual has a relevant financial relationship if such person (or his/her spouse/partner) has a financial relationship in any amount occurring in the last 12 months with a commercial interest. OHE ensures that the content is independent of commercial bias.
Ms. Chart and Ms. Gleason have indicated that they are employees of and own stock in UnitedHealth Group.
The remaining activity faculty or planners have no financial relationships to disclose.
Method for calculating CE credit
CE credit was calculated by the complexity of content.
In support of improving patient care, OptumHealth Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.
Credit designation statements
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.
OptumHealth Education designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.
This program meets AAPC guidelines for 1.0 CEU. Can be used for Core A, CANPC and CHONC with successful completion of post-activity assessment for continuing education units.
A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.
- 1.00 AAPC - Coders
- 1.00 AMA - Physicians
- 1.00 Attendance - General Attendance
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