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Preferred Health Partners uses Matrix Medical

Network’s Physician Bulletin Program to improve


physician chart documentation, upgrade Medicare
Advantage member care and optimize its risk
adjustment funding.

“ .”
Case Study

We wanted to identify opportunities for enhanced Summary


diagnosis documentation to better care for our To help upgrade and streamline
the medical documentation
Medicare Advantage members,” explained Dennis Price. program for its Medicare Advantage
“We also wanted to reach out to our physicians and members, Brooklyn-based Preferred
establish a more collaborative relationship around Health Partners (PHP) adopted
chart documentation. Matrix Medical Network’s Physician
Bulletin program in 2010. After
working with Matrix to integrate
Need to streamline documentation the program into its system and
“We had a challenge,” admitted Dennis Price, Executive Vice President introduce it to its 180 primary care
of Financial Affairs and Business Development for the Brooklyn-based physicians and specialists,
medical group Preferred Health Partners (PHP). In 2010, with more PHP has improved continuity
than 13,000 Medicare Advantage enrollees, PHP wanted to streamline of care to its 13,000 Medicare
and improve its physician documentation program. Advantage members and
dramatically improved the accuracy
The group was proud of the care its more than 180 multilingual
and completeness of its HCC
board certified primary care physicians and specialists were
diagnoses. During the three years
providing members but PHP management felt there was room for
the program has been in place,
improvement. “We wanted to identify opportunities for enhanced
the Health Plan Medicare Risk
diagnosis documentation to better care for our Medicare Advantage
Adjustment funding has increased
members,” explained Dennis Price. “We also wanted to reach out to
by $38 million and PHP has
our physicians and establish a more collaborative relationship around
received approximately $13 million
chart documentation.”
as its share of the revenue.
Case Study

A physician-centered approach
After looking into expanding its own Medicare risk auditing systems and
consulting outside suppliers, PHP turned to Matrix Medical Network
and its new Physician Bulletin program for a solution. “We liked Matrix’s
robust analytics and the physician-centered approach of its Physician
Bulletin,” said Dennis Price.
“Matrix’s Physician Bulletin was also appealing because it is not merely
another retrospective review of diagnoses,” says Michelle Beckford,
Coding Supervisor for PHP’s coding compliance department. “It drills
down into members’ data and identifies highest priority diagnostic HCC


opportunities for our physicians before their Medicare Advantage patient
appointments. That impressed us.”

Re-organizing around the Physician Bulletin Matrix helped us


After meeting in the summer of 2010 with Larry Bishoff, the president
combine our own
of Matrix’s Medicare Advantage Review division, Dennis Price and his
PHP staff began re-organizing the group’s documentation and coding internal members’
programs around Matrix’s Physician Bulletin. “One of the first steps was medical records with
enhancing our data collection,” says Michelle Beckford. hospital, laboratory,
Michelle Beckford and others at PHP worked with Matrix’s analytics pharmaceutical,

.”
team to create a new, more comprehensive database for the group’s therapist and other
Medicare Advantage members. “Matrix helped us combine our ancillary data to build
own internal members’ medical records with hospital, laboratory,
pharmaceutical, therapist and other ancillary data to build a wide-ranging
a wide-ranging records
records and claims database,” says Michelle Beckford. and claims database.
Data, and data mining, are at the very heart of the Physician Bulletin
program. Using powerful analytics, including clinical algorithms that
were designed by MDs, coding experts and other healthcare and IT
professionals at Matrix-owned Ascender, the program mines this data to
identify likely missing HCC diagnoses.
“Basically, what we’re looking for are red flags that indicate a condition
a physician may have overlooked or merely not documented in
accordance with Medicare guidelines,” says Larry Bishoff. Common
“catches” are patients with undocumented comorbidities. For example,
diabetes patients may only have the primary disease coded and not
manifestations. Often the program’s clinical algorithms will spot a medical
prescription for a condition that has not been referenced in the chart.
After possible missing--or improperly documented--HCC diagnoses are
pinpointed, Matrix nurse reviewers, working remotely, scan the electronic
chart. They validate the findings from the algorithms, and often add
recommendations from chart documents, such as consultants’ reports,
that could not be included in the data.
Case Study

» They then prepare the electronic Physician Bulletin, which is sent to a


group’s physician one or two days prior to the patient’s examination.
“We worked with PHP to set up electronic delivery of the Bulletins


and receipt of completed documents from the physicians,” explains
Larry Bishoff.
These concise, one-page Physician Bulletins may contain up to three
possible recommendations or “diagnostic opportunities.” Typical Thanks to our data
wording: “Congestive Heart Failure, Unspecified. Rx claims data gathering capabilities,
show that COREG and LASIX have been prescribed for this patient.
our robust analytics,
Please consider documenting this diagnosis for 2013 if patient meets
criteria.” Says Larry Bishoff, “Thanks to our data gathering capabilities, which we are
our robust analytics, which we are continually refining, and our remote continually refining,
chart review, our Physician Bulletins have proven to be very accurate. and our remote chart
We are typically getting over 70% percent physician verification of our review, our Physician
recommendations.”
Bulletins have proven to
Implementing the Physician Bulletin be very accurate.

.”
PHP instituted new coding methods and designed a new electronic We are typically getting
portal and other platforms to support the Physician Bulletin’s reporting over 70% percent
program. “We made the decision to invest a lot of our own resources to physician verification of
help make this new documentation program as seamless as possible,” said our recommendations.
Dennis Price. Initially, there was a lot of back and forth consulting with
Matrix’s technical staffers to streamline and coordinate the systems but
within three months the Physician Bulletin program was up and running.
As part of taking ownership of the new Physician Bulletin process, PHP
management knew it was important to educate its physicians about
the advantages of the new program. “Changing a culture is always a
challenge,” says Michelle Beckford. “One of the real benefits of these
bulletins is that they are proactive. After our physicians realized the
bulletins were alerting them about possible conditions before they
saw their patients, they quickly realized there was potential to improve
patient care. It made the transition process that much easier.”
After seeing a patient, PHP physicians return the Physician Bulletin, with
actions taken and comments noted, to PHP and Matrix. PHP coders
check the completed bulletins and adjudicate them. They are also sent
electronically to Matrix to confirm the documentation. “That way
Matrix will know the diagnosis has been captured and won’t need to be
included on future bulletins,” explains Michelle Beckford.
PHP also alerts Matrix about any possible HCC diagnoses that their
doctors may have disagreed with. Matrix then uses this information to
recalibrate their clinical algorithms, ensuring future Physician Bulletins are
as accurate as possible.
Case Study

Results


It didn’t take long for us to see results from our adoption of the
Physician Bulletins,” said Dennis Price. Almost immediately PHP
physicians were diagnosing conditions, such as comorbidities, that had
been missed or overlooked. Others noted that the bulletins helped Our doctors told us
them identify medical issues early on.
they appreciated the
“Our doctors told us they appreciated the way these bulletins way these bulletins
contributed to continuity of care,” says Michelle Beckford. “They tell us
the Physician Bulletin’s ‘red flags’ help them ensure they are giving their
contributed to
Medicare Advantage patients the care they deserve. Now, if for some continuity of care,”
reason they haven’t received a bulletin on time, they will call us and ask says Michelle Beckford.
us for it. They look forward to using them to treat their patients.” “They tell us the
During 2012 alone Matrix sent out 7086 Physician Bulletins, which Physician Bulletin’s ‘red
included a total of 10,292 HCC diagnoses to PHP’s doctors. PHP’s flags’ help them ensure
physicians say they value the conciseness of the one-page bulletins,
they are giving their
their simplicity and the accuracy of their recommendations. Indeed,
PHP reports that its physicians agree with the bulletins’ Diagnostic Medicare Advantage
Opportunities about 80 percent of the time. patients the care they
One way to measure how the Physician Bulletin program has improved deserve. Now, if for
PHP’s Medicare Advantage patient care and documentation is by looking some reason they
at the group’s Medicare’s Risk Adjustment Factor (RAF). PHP’s results haven’t received a
have been dramatic. bulletin on time, they

.”
Before adopting the bulletin program, PHP’s RAF was .94. After the first will call us and ask
year with the Physician Bulletin in place that jumped to 1.01. A year later
us for it. They look
it rose to 1.08. “And we are on track to report a RAF of 1.12 for this
year,” said Dennis Price. As he pointed out, the difference between an forward to using them
RAF of .94 and 1.12 in Medicare Risk Adjustment funding is about to treat their patients.
$19 million.
Since starting the Physician Bulleting program, enhanced system
revenues, which are divided between the Medical Group and the
insurance company, have risen each year. Enhanced system revenues for
2010 were about $6 million; in 2011 they rose to $13 million and to
$19 million in 2012.
“That’s $38 million more for the Health Plan and us to care for our
patients,” said Dennis Price.
While the financial benefits of Matrix’s Physician Bulletin program to PHP
are encouraging, it is the improvement in patient care that management
is proudest of. Each Fall PHP receives a list from Matrix of between 500-
700 of its Medicare Advantage patients who have relatively high RAFs but
have neglected to come in for treatment during the year.
Case Study


“These are patients that should be seeing a doctor every three or four
months,” said Dennis Price. “They were falling through the net before. These are patients
But now Matrix’s strong algorithms help us identify and notify them. It’s that should be seeing
nice to know that this technology is helping us take better and better
care of our members.”
a doctor every three
or four months,” said
Dennis Price. “They were
Ascender Software, a division of Matrix Medical falling through the net
Network before. But now Matrix’s
Ascender Software, a division of Matrix Medical Network, is a national
strong algorithms help us
leader in health care analytics for medical groups, IPAs, MSOs, and identify and notify them.

.”
health plans. Ascender’s comprehensive solutions facilitate improved It’s nice to know that
quality and risk scores through HEDIS, P4P, PQRS, STARS, and HCCs this technology is helping
across multiple payer markets: Medicare, Medicaid, and commercial. us take better and better
Ascender’s web-based tools empower organizations to reduce costs,
improve patient satisfaction, and increase revenues through focused
care of our members.
population management. In combination with Matrix Medical Network’s
prospective risk adjustment solutions, Ascender clients can access a full
spectrum of services including software, analytics, clinical chart reviews,
coding, and in-home patient assessments.

About Matrix Medical Network


Matrix is headquartered in Scottsdale, Ariz., and provides in-person
prospective medical assessment and transition of care services that help
medical plan clients manage costs and provide high-quality care. Having
pioneered the use of a national network of highly-trained employee
Nurse Practitioners to conduct medical assessments in plan member
homes or nursing facilities, Matrix is dedicated to improving the quality
of healthcare in the U.S. through offering affordable home-care service
options; helping clients efficiently, accurately, and securely collect plan
member information; and providing data analytic and risk adjustment
solutions that improve clinical outcomes. Matrix is owned by Welsh,
Carson, Anderson & Stowe, a leading private equity investment firm.
For more information, visit www.MatrixForMe.com.

For More Information


To find out how Ascender Software can help you enhance
revenue growth and improve patient care, call us at
619.955.7847/800.569.1222 or visit www.ascendersoft.com.

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