Managed Care

CTMs - Determining Risk

  • 1.  CTMs - Determining Risk

    Posted 03-27-2019 12:48 PM
    With regard to complaint tracking through HPMS, I know CMS reviews # of complaints per 1000 members, which then determines your outlier status in comparison with other plans.  It's been my experience that plans aren't aware they are an outlier until receiving notice from their account managers.  Is there a better way to work the formula yourself to determine when you may or may not be reaching that outlier level?  Any insight or advice would be greatly appreciated.

    Thank you,
    Nichole

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    Nichole Hageman
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    2019 HCCA Compliance Institute


  • 2.  RE: CTMs - Determining Risk

    Posted 03-27-2019 03:14 PM
    Nichole,

    The calculation is found in each year’s Medicare Part C & D Star Rating Technical Notes.

    For 2019:
    [ (total # of all complaints logged into the CTM) / (Average contract enrollment) ] * 1000 * 30 / (# of days in period).

    # of days in period = 366 for leap years, 365 for all other years.

    Cut points:
    1 Star: > 0.64
    2 stars: > 0.31 to <=0.64
    3 stars: > 0.18 to <= 0.31
    4 stars: > 0.10 to <= 0.18
    5 stars: <= 0.10

    Sent from my iPhone


    2019 HCCA Compliance Institute