NY Medicaid
Reimbursement for Medicaid Managed Care Plans is undergoing a significant change in New York. The State is collecting information that will be used to risk adjust health plan reimbursement based on 3M Health Information Systems’ (HIS) Clinical Risk Groups (CRGs). In the spring of 2008, 25% of each Managed Medicaid Plan’s payment is based on the new risk scores. By 2011, 100% of reimbursement is expected be risk adjusted.
New York State’s actuarial vendor, Mercer, will be extracting diagnostic, procedural and pharmacy information from claims, which will become the inputs for the CRG algorithm. The potential of under-coding is a threat to health plans since risk-adjusted reimbursement presents the real possibility that plans will be paid less than at present, or less than appropriate, if the clinical complexity of members served is not documented.
Using the CRGs, CareAdvantage has tools and methodologies to assist health plans in managing and understanding this change in reimbursement methodology, identifying opportunities for improved coding and other potential revenue opportunities. CAI has been working with the CRG algorithm for over 7 years, has contributed to their evolution and has used the CRG algorithm to create predictive modeling and decision support tools for population management. CRGs provide a more defined level of member categorization by their disease and comorbidities and by using these tools a health plan can identify the high opportunity members that would benefit from care management.
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