Revenue optimization is integral to the financial success of a Health Plan. It allows a Health Plan to be profitable as well as grow in membership due to the ability to provide more attractive benefits than their competitors.
LD brings a breadth and depth of experience in Medicare Advantage (MA) premium capitation administered by CMS. LD has experience in modeling, reporting and revenue optimization initiative development around the CMS-HCC model. LD assists clients in the CMS MA bid process with regards to bid risk score development which ensures future year’s financial success. LD assists plans in developing programs which ensure that member conditions are complete and accurately reported to CMS and ensure that capitation premiums received from CMS are correct. We audit encounter and RAPS submissions for accuracy as well as advise on prospective and retrospective ICD coding initiatives. LD also assists Finance Departments within Health Plans to develop accruals of future revenue accurately for Mid-Year and Final Settlement Adjustments as well as revenue budgeting and forecasting.
LD’s CMS-HCC model expertise can also be leveraged for other Accountable Care Organizations participating in CMS program’s (Medicare Shared Savings Program, etc.)
LD brings experience in Medicaid MCO revenue management and optimization, specifically for MCOs in the Maryland HealthChoice program. Similar to Medicare, LD audits Medicaid encounter submissions to the State for completeness and accuracy as well and report on their associated revenue impact. LD is well versed in ACG, CDPS and other risk adjustment programs to these ends. Often Health Plans can influence their future reimbursement by participation in rate setting meetings with the State which LD can consult on content and strategy.
Both Medicare Advantage and Medicaid MCOs must make certain their members are receiving quality care to capture their optimum revenue. LD has experience in auditing of encounter submissions as they impact quality, and thus revenue, and their financial impact. LD can calculate and track many of the NCQA HEDIS measures which impact Star Ratings in MA and Value Based Purchasing measures in Maryland Medicaid.
LD Consulting 