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Quality Assurance

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The Challenge

In December of 2010, a Medicare Advantage Plan learned that it was going to assume responsibility for the management of roughly 4,000 new elderly members from another health plan. These Medicare Advantage members needed to have a health risk assessment (HRA) performed very quickly so the Plan could triage them to the proper medical management programs, target specific members for additional HCC coding, and develop strategies to keep these new members healthy.

The challenge for the Plan was how to do this quickly and efficiently, so they called LifePlans.

The Solution

Given LifePlans experience conducting telephonic health risk assessments for more than a decade, the LifePlans team quickly moved into action to:

Weeks 1-3

  • Create a customized comprehensive telephonic HRA to meet the Planís objectives and be compliant with all CMS requirements
  • Develop a risk classification algorithm that would flag high risk members and those potentially in need of an in-home visit by a nurse practitioner for proper HCC coding
  • Program the HRA into the LifePlans IT infrastructure
  • Automate all scripting and call processes

Week 4:

  • Program was operational and LifePlans began to reach out to new members

The Results

Within a 45 day period, LifePlans completed HRAs on 80% of all members that were reached:

  • Attempted up to 6 calls for each member
  • Recorded the disposition of all call attempts and provided them to the Plan in electronic format

LifePlans provided the case management unit at the Plan with daily alerts of the high risk members identified using the risk classification algorithm from calls made the preceding day. Additionally, LifePlans:

  • Recorded all completed calls and stored all data elements into a database transferred to the Plan
  • Generated a report and recording for each completed HRA and made them available to the Plan

LifePlans completed an aggregate descriptive analysis so that the Medicare Advantage Plan had a much better and more comprehensive clinical picture of the new members that had joined the plan only a few weeks earlier. This enabled more effective medical management and assured that members were coded properly given their underlying conditions.

The success of this program has led the Medicare Advantage Plan to engage LifePlans on a new assessment program related to falls prevention and bathroom safety.