Speaker Presentation
Tuesday, June 11, 2019

Registration & Continental Breakfast

Sponsored By: Strategic Solutions Network (SSN), based in Boca Raton, FL, is the parent company of the Medicare Risk Adjustment & Revenue Management Management, Plus Quality and Star Ratings and a series of related conferences.


Chairperson’s Welcome

Dr. Tracey Veal, PhD, MBA Sr. Director, Strategic Programs, Aetna

Integrating Stars, Quality & Risk Adjustment to
Boost Performance Scores, Ensure Compliance & Control Costs

Balancing CMS Regulations With Your Business Needs

This session will provide a brief overview of recent Medicare Advantage changes in regulation and initiatives.

  • Review major MA regulatory changes finalized in the past year
  • What can we expect from MA in 2020 and beyond?
  • How to be proactive in regulatory process
  • Use of forthcoming regulatory changes to guide your business strategy

Aldiana Krizanovic, MPH, CPH Senior Health Policy Consultant for Federal Government Relations, Florida Blue


Breaking Down Silos and Coordinating Process Flows

We know that achieving Star ratings is critical to any MA organization's success. But, how do we go about accomplishing this in an unintegrated delivery model? With so many stakeholders and systems to coordinate, and seemingly fewer resources to invest in quality, this session will explore strategies in which MA plans can set themselves up for success in designing a quality program that works. We'll look at ways in which we can break down silos within the plan and its providers in order to better coordinate process flows to achieve desired outcomes. We'll look at ways in which we can break down silos within the plan and its providers to:

  • Improve organizational efficiency via cross-functional workgroup design
  • Gain leadership buy-in to support quality improvement programs
  • lign provider partners on strategy to achieve desired outcomes

Michelle Fujii Director of Network Quality, SCAN Health Plan


Case Study: Gateway Health Plan -- Building a Foundation for a Successful Future

Achieving success in Medicare Advantage Stars Ratings requires strategic planning, executive sponsorship, and investment in core foundational interventions and processes. Gateway Health Plan has begun the transformation into a 4 Star Dual plan built around a foundation of proven intervention strategies, program management processes, and a matrixed operating model. This session will share the highlights of that transformation and the guiding principles that are changing Gateway Health Plan’s trajectory.

Dan Weaver Vice President, Stars Quality, Gateway Health Formerly Director of Program Management, Government Business, Quality Improvement Highmark

Mick TwomeyPresident and Chief Operating Officer, Hyperlift, Inc.


Networking Refreshment Break

Improve Provider Engagement & Data Sharing

Panel Discussion: Maximizing Provider Data and Data Sharing

Maximizing provider data and data sharing becomes more critical between the payer and provider groups to improve care coordination, care quality, and optimize star measure performance. This session will provide insights and experience on how to maximize your provider data and sharing of the data.


Dan WeaverVice President, Stars Quality, Gateway HealthFormerly Director of Program Management, Government Business, Quality Improvement Highmark


David L. Larsen RN, MHADirector, Quality Improvement, Select Health

Debra A. CorbettProgram Director, Senior Products Clinical Services Strategy, Tufts Health Plan

Stephanie GutendorfVice President of Medicare Growth and Strategy, Livongo


Migrating Risk Adjustment into the Primary Care Office

Primary Care Physicians are in the best position to identify and validate diagnoses, close quality of care gaps, and maintain continuity of care for their patients. Engaging PCPs with the proper incentives, data, and clinical support has been an ongoing challenge for health plans.

We will review successful strategies and case studies where PCPs perform complete and accurate diagnostic coding in the office to maximize risk adjustment yield, reduce RADV audit risk, and close quality of care gaps. Our presentation will also compare the benefits of in-office to in-home assessments and retrospective chart views.
Learn the pros and cons of prospective and retrospective risk adjustment strategies

  • Understand how to integrate clinical data from the EMR and claims data from the health plan into the PCP workflow in an office setting
  • Drive higher compliance to satisfy CMS requirements and reduce RADV audit risk
  • Develop strategies to maximize yield and improve compliance at the same time

Dr. Hassan RifaatChief Executive Officer, Vatica Health


Building Provider Relationships to Achieve Enhanced Quality Performance and Improved Patient Outcomes

Closer collaborations and integrated partnership between a payer and provider group build trust leading to opportunities for success in many areas. Learn how to customize your quality assistance programs for the unique needs of each provider group. Find out how you can demonstrate your value by soliciting feedback on how to best assist provider groups and subsequently assess and accommodate the requests. Get examples of the value add you can offer including: education, care management resources, workflow ideas, and data sharing. And, set up effective communications to ensure ongoing collaborative identification of provider specific needs.

Debra J. Zeh BSN, RNSr. Director, Quality Improvement, Provider Performance, UPMC Health Plan


Aligning Provider Contracting with STARS, Quality & Risk Adjustment

James LewisVice President of Quality, STAR & Risk Revenue Programs, Blue Cross Blue Shield of Arizona Advantage


Networking Lunch


Supplemental Data Collection and Utilization to Boost HEDIS & Stars Performance

Supplemental data is increasingly important in improving HEDIS and STARS performance. This session will provide information to develop strategies to improve rates including:

  • Measure selection
  • Standard versus non-standard collection
  • Regulatory changes impacting data collection
  • Data analysis to improvement both provider and member engagement

Susan LiraManager, Plan Performance & Improvement, Capital BlueCross

Enhancing Member Engagement & Transparency

A Team-Based Approach to help Increase CMS-Star Rating

Alone we can do so little, but together we can do so much. This session will outline the fundamentals of addressing the care gaps, while utilizing a team based-approach methodology, comprised of clinical and non-clinical professionals to help maximize efficiency, while increasing Star ratings. These are core topics that will be discussed to achieve results:

  • Key Measures addressed
  • Professionals associated with the program
  • Targeted member outreach
  • Tracking results

Christine SwanVP of Call Center Operations, Axion Contact


Improving Consumer Survey Results (CAHPS) – Medicare Advantage Lessons Learned

  • Consumer Assessment of Healthcare Providers & Systems (CAHPS) Level setting patient experience versus patient satisfaction
  • Questions & Intent
  • Evidence-based & alternative approaches to improving relevant member experiences
  • Resources

Dr. Tracey Veal, PhD, MBASr. Director, Strategic Programs, Aetna


Increasing Performance on the 5 HOS STARs Measures

  • Improving or Maintaining Physical Health
  • Improving or Maintaining Mental Health
  • Monitoring Physical Activity
  • Improving Bladder Control
  • Reducing the Risk of Falling

Debra A. CorbettProgram Director, Senior Products Clinical Services Strategy, Tufts Health Plan


Networking Refreshment Break


Addressing Star Ratings through Implementation of an Appointment-Based Medication Adherence and Population Health Strategy

Achieving success in Medicare Advantage Stars Ratings requires

  • Partnering with a high performing pharmacy network
  • Effective leveraging of technology in daily operations
  • Utilization of analytics to determine the appropriate intervention for the right patient
  • Mark J. Gregory, RPh, Director, Population Health Division, Omnicell
  • Creative risk based payment models

Mark J. Gregory, RPh Director, Population Health Division, Omnicell


Case Study: Changing the Way We Care for Our Members -- Geisinger’s Approach to Addressing Social Determinants of Health

Highlight the impact that SDOH have on our patients. Addressing food insecurity through a “Food as Medicine” approach:

  • Program description
  • Clinical outcomes
  • Community partnerships
  • Pilot discussion
  • Vendor solution
  • Plans moving forward
Harnessing AI for Behavioral Health Interventions
Quality initiatives & benefit redesign/discussion at insurance provider level

Maria WelchSenior Wellness Specialist, Steele Institute for Innovation, Geisinger


SDOH and Community Partnerships – Building Collaborations

  • Overview of SDOH work at CareSource – JobConnect, Housing and Food Access pilots
  • Discussion of how community partnerships play a vital role
  • Metrics to date and impact on quality

Karen VanZant Vice President, Executive Director, Life Services, CareSource


Networking Reception

Sponsored By: Strategic Solutions Network (SSN), based in Boca Raton, FL, is the parent company of the Medicare Risk Adjustment & Revenue Management Management, Plus Quality and Star Ratings and a series of related conferences.

Wednesday, June 12, 2019

Networking Continental Breakfast


Chairperson’s Remarks

Dr. Tracey Veal, PhD, MBA, Sr. Director, Strategic Programs, Aetna

Cost & Quality Control of Care Delivery

Case Study: In Home Assessments -- Closing Gaps in Care and Gathering Quality and Risk Adjustment Data

Health Plans are challenged to close Quality and Coding Gaps in Care. Some members don’t see their PCPs unless they have symptoms, and others may not show up for additional advanced diagnostic testing. Access can be an issue in some places. Innovative care gap strategies such as home or mobile visits can provide for convenient advanced screenings and diagnostic testing for members.

Karen Manning, Director Strategic Quality Programs, Interim Director Medicare Revenue Operations, Martin’s Point Health Care


Embracing Technology to Transform Care Delivery and Improve Health Outcomes

The infrastructure of the U.S. healthcare system makes it near impossible for large payers to layer on innovative technologies that will have a real impact. Current systems are too fragmented, and data is too messy, to generate the insights to assess risk in real time and deliver quality preventive care. To make a real difference for our members, we must work not only to implement new technologies, but better ones. Systems that PCPs will actually use, that complement—do not replace—current documentation processes, and prioritize immediate patient needs. This session will highlight examples of technologies that improve the patient experience at the POC to lead to better health outcomes, including an overview of Clover’s success in implementing the Clover Assistant.

Erica Pham, Deputy General Counsel and Head of Government Affairs, Clover Health


Case Study: Effective Community Pharmacy Partnerships Aimed at Boosting Star Medication Adherence Performance

As health plans recognize the substantial impact of the triple weighted Star Medication Adherence measures in relation to overall Star rating performance, efficient member engagement strategies will need to be deployed to either sustain or boost Star ratings. This session will discuss the advantages of establishing community pharmacy partnerships, and best practices for successful implementation for sustainable Medication Adherence Star measure results.
Concepts include: Recognizing the advantages and disadvantages of Medication Adherence pharmacy partnerships

  • Effectively designing pharmacy partnerships for greatest Star measure impact
  • Strategies to optimize the value and performance of Medication Adherence pharmacy partnerships

Alyssa M. Tutino, PharmD, Quality Improvement Clinical Pharmacist, Excellus BlueCross BlueShield


Networking Refreshment Break


Position Your Plan to Respond to Rising Cut Points While Addressing Other Part D Measures

CMS is sending a message that CMR completion rates are meeting their expectations. Cut points are rising that plan performance. What can you do to best position your plan to respond to those rising cut points while not losing site of the other Medicare Part D measures? With more than a decade experience with the CMS measures, Donovan will provide insight into how to best position your organization and utilize your resources in response to CMS’ position.

Donovan Lemelin Director of Operations, Medicare Pharmacy, Molina Healthcare

Risk Adjustment Revenue Management Tools and Strategies

Prospective Program Alignment Across Quality and Risk

  • Member engagement and targeted outreach
  • Quality measures and Provider Incentives
  • In-home visit considerations

Gaurishankar Chandrashekhar Director Revenue Management, Harvard Pilgrim Health Care


Risk Mitigation Strategies in Risk Adjustment (MA and ACA)

Regulatory requirements related to the submission of Risk Adjustment data and RADV audits have driven health plans to develop and implement appropriate safeguards to ensure plans submit complete and accurate data for reimbursement purposes. Whether your health plan outsources or internally manages Risk Adjustment data collection and submissions capabilities, adding an extra layer of confidence is a prudent investment. This session will include a discussion of risk mitigation strategies, from both a data analytics approach and coding validation techniques, for submitting Risk Adjustment data.

Olga Ziegler Vice President, Revenue Program Management, Highmark


Case Study: Review and Reconciliation of RAPS and EDPS Data

Medicare Advantage Organizations (MAOs) are required to submit risk adjustment data through RAPS and EDPS. As CMS gradually phases EDPS data into payment by blending risk scores, many organizations are faced with the challenges of submitting the data and reconciling and reviewing these data to ensure accurate risk adjustment payments. UPMC Health Plan will share their

process for reviewing and analyzing these datasets to ensure complete and accurate submission of data to CMS. This session will cover the process from reconciling submission data through transforming and analyzing the risk scores from both sources.  This thorough analysis, as well as participating in industry wide studies has prepared UPMC Health Plan for this transition while minimizing risk.

Tim Plank Manager of CMS Encounter Data, UPMC Health Plan


Close of Conference