United Healthcare Medicare Advantage

1. United Healthcare & Medicare Advantage

2. CMS � HCC Risk Adjustment ModelThe Role of Physicians and Supporting Staff Idaho Physicians Network Tuesday, April 12, 2011 Amanda Day Notes included with each slide for ease in script review. Make edits in the matching word document, with Track Changes turned on.Notes included with each slide for ease in script review. Make edits in the matching word document, with Track Changes turned on.

3. � Ingenix, Inc. 3 Ingenix � Who are we? What do we do? Ingenix is working as a consultant on behalf of UnitedHealthcare Secure Horizons � AARP Medicare Complete Evercare Ingenix specializes in Risk Adjustment services Clinical Tools Educational Programs Provider Based Incentive Programs Chart Review Services aimed at helping you identify and manage your Medicare members that have chronic conditions such as diabetes, CKD and heart disease.

4. � Ingenix, Inc. 4 Historically - Medicare paid Medicare Advantage plans a monthly capitation rate to provide health care services to enrolled beneficiaries Previous methodology based solely on demographics Now - Hierarchical Condition Category (HCC) Risk Adjustment Payment Model Based on chronic conditions Designed to direct more money to plans enrolling sicker beneficiaries or to plans specializing in treating high-cost populations Focuses on beneficiaries with particular chronic diseases or high levels of functional impairment Payment Methodology � Then & Now

5. � Ingenix, Inc. 5 HCC Risk Adjustment Model Hierarchical Condition Category Applies hierarchies to disease categories 70 disease categories; over 3,100 diagnoses A �risk factor� or coefficient is assigned to each category �Additive� Model Includes all qualifying diagnoses �Predictive� Model 2012 payment based on 2011 DOS Adjusts payments based on health status Chart documentation and diagnosis coding

6. � Ingenix, Inc. 6 HCC Risk Adjustment Model Health status must be re-determined each year Must be assessed, treated and documented in the medical record annually Based on diagnosis reported through claims/encounter data Higher importance to document and code all conditions that are evaluated at each visit Health status is the primary driver of CMS revenue

7. � Ingenix, Inc. 7 Risk Adjustment Factor (RAF) Scores Risk factors or coefficients for a patient add up to equal a risk adjustment factor (RAF) score in order to give a clinical picture of the patient�s health status RAF scores are assigned to a member, but roll up to a provider based on the member�s assigned primary care provider CMS suggests that an average senior who is generally healthy should have a RAF score on average of 1.00 RAF scores below 1.00, suggest a healthy patient RAF scores above 1.00, suggest a patient with chronic conditions

8. � Ingenix, Inc. 8 Interpreting the RAF RAF score simply identifies patient health status Lower RAF score indicates a healthier population A lower RAF score may also indicate the following issues It may be falsely indicating a healthier population because of a lack of adequate chart documentation or complete and accurate ICD-9 coding Patients have not been seen It may be indicative of insufficient claims data submission

9. � Ingenix, Inc. 9 What All Providers Need to Know� Documentation is key If it�s not documented, you cannot support your diagnosis If it�s not documented, you can�t bill for it All conditions must be coded in order to trigger appropriate reimbursement for this model ICD-9 coding to the highest level of specificity and accuracy is essential What is your group�s overall RAF score? Is your documentation sufficient to fund the care for your sicker patients?

10. � Ingenix, Inc. 10 Health Plan Goals Early detection, ongoing treatment and accurate reporting of chronic conditions drive improved health outcomes Annual assessment of members Early assessment of chronic conditions Ongoing assessment of chronic conditions

11. � Ingenix, Inc. 11 How can we help? Ingenix Tools and Resources Clinical programs aimed at increasing early detection of disease Customized Reporting Packages Provider based Incentive Programs The Patient Assessment Form Program Coding Classes Chart Review Access to certified coders Access to the Ingenix Clinical Team

12. � Ingenix, Inc. 12 Ingenix Team David Gardineer Market Outreach Consultant Ingenix - Desert Mountain Region 702.240.8978 *: david.gardineer1@ingenix.com Amanda Day Associate Director, Market Outreach Ingenix - Desert Mountain Region ' 702.240.8876 *: amanda.day1@ingenix.com

13. � Ingenix, Inc. 13 Thank you for your time!