Blogs

Telehealth Risk Adjustment by Line of Business

Telehealth Risk Adjustment by Line of Business

Written by Ted Kyi

May 5, 2020

I know I have focused on Medicare Advantage in my posts here, which is a reflection of both the size of the risk adjustment market for MA, as well as the lack of clarity about risk adjustment which had surrounded MA.  Here is a recap of how telehealth visits can be used for risk adjustment by line of business:

Medicare Advantage – telehealth is allowed, requires video with audio for diagnoses to count toward risk adjustment

ACA commercial – telehealth allowed, state regulation of the practice of medicine determines allowed modalities (audio-only or video)

Medicaid – regulation delegated to the states, so also state-by-state which modalities allowed.  Note that Medicaid regulations about telehealth aren’t always the same as the regulations that govern ACA in the same state. For example, in Georgia, “standard telephone” calls do not constitute telemedicine services, but the Georgia Medicaid waiver explicitly allows telephone communication.

CMS has extended section 1135 waivers for many states, allowing them to relax rules during the public health emergency.  These waivers cover expanded use of telehealth, reduced cost sharing, as well as extending out of state license reciprocity.  Three great resources for tracking the individual state regulations on licensure and telehealth regulations are:

National Council of State Boards of Nursing (NCSBN)

Federation of State Medical Boards (FSMB)

Center for Connected Health Policy (CCHP)

You should also refer to the CMS website for the list of approved state waivers.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Telehealth Visits Will Risk Adjust for Medicare Advantage

Telehealth Visits Will Risk Adjust for Medicare Advantage

Written by Ted Kyi

April 10, 2020

The official guidance which those of us in the risk adjustment community have been waiting for has finally arrived.  Exactly one month after the HPMS memo authorizing MA plans to expand use of telehealth, the agency has announced that diagnoses from telehealth visits will be included in risk adjustment calculations.

The requirements are that the encounter meet the usual face-to-face rules, and that the telehealth use audio and video.

CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter….  Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


MA Final Notice Silent on Risk Adjustment for Telehealth

MA Final Notice Silent on Risk Adjustment for Telehealth Visits

Written by Ted Kyi

April 6, 2020

As I suspected, the final notice for MA and Part D came out today, and it does not address whether telehealth visits will risk adjust. In the announcement, CMS is limited to finalizing regulations which were proposed in the Advanced Notices and went through public comment. For this reason, telehealth needs to be addressed separately. Guidance about telehealth may come soon, but it will be under the umbrella of the Section 1135 waiver authority of the public health emergency. Stay tuned!


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Matrix Featured as an Active Employer During the COVID-19 Pandemic

Matrix Featured as an Active Employer During the COVID-19 Pandemic

Matrix Medical Network joins Glassdoor’s list of 33 companies eager to hire amid COVID-19

During the COVID-19 pandemic many people may find themselves in difficult situations, especially in the workplace as the coronavirus disrupts the American economy. Despite this uncertainty, Matrix Medical Network continues its commitment to reaching health plan members across the country and was recently featured by Glassdoor as one of 33 companies eager to hire amid COVID-19.

The article, which features Matrix among hospitals, health care services and additional organizations that are actively hiring, highlights several open positions at Matrix for nurse practitioners, physician assistants, medical coders, contact center representatives and many more career fields across the country.

Now more than ever, Matrix is dedicated to serving vulnerable populations, including older Americans and those with chronic conditions who are at the highest risk of suffering severe illness and who are often the most difficult health plan members to reach.

Matrix providers are uniquely positioned to make an impact on these populations by meeting them in the safety and comfort of their homes where clinicians are then able to provide valuable care, education and resources. During the current COVID-19 pandemic, these in-home visits serve not only to inform of best practices and CDC guidelines for preventing the spread of the virus, but also eliminate the need for members to leave their home and enter high-contagion areas.

By continuing to expand its network of 3,000+ nurse practitioners in the field and additional corporate and clinical support staff in Scottsdale, Arizona and Largo, Florida, Matrix continues its commitment to bringing care directly to members where they live.

Learn more about the innovative and collaborative work culture you can discover at Matrix by visiting our careers page or view our open positions across the country.



Telehealth as an Alternate Modality for Medicare

Telehealth as an Alternate Modality for Medicare

Written by Ted Kyi

March 17, 2020

Today, CMS published a fact sheet and FAQ which answered a lot of questions about the use of telehealth for Medicare beneficiaries.  I still have questions as to the degree to which these announcements pertain only to FFS Original Medicare, or also apply to Medicare Advantage.

To understand today’s documents, we have to go back to March 6, 2020 when H.R.6074 — the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 — was signed into law.  This act amended the section 1135 waiver authority granted to the HHS Secretary.  Secretary Azar declared a public health emergency on January 31, 2020, and as soon as the act became law, used the expanded section 1135 waiver to broaden access to telehealth services so that Medicare beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility.

The waiver applies to three virtual services:  Telehealth visits, Virtual check-ins, and E-visits.  In brief, these services are defined as:

  • Telehealth visits pertain to general office visit services
  • Virtual check-ins are brief communications with established patients
  • E-visits are communications with established patients via an online patient portal

Wearing my risk adjustment hat, prospective health assessments, like the Matrix Comprehensive Health Assessment, are neither brief nor patient initiated through an online patient portal, so they align with telehealth visits.

Under the telehealth visits provision, visits with a provider (which include NPs) that generally take place in-person may take place using audio and video telecommunications between a distant site and the patient at home.  The usual restrictions regarding a prior established relationship or the originating site are explicitly waived.

Additionally, providers are allowed to use everyday communications technologies, such as FaceTime or Skype, without fear of penalties for HIPAA violations.

“Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.”

This will make a significant impact on the ease with which providers will be able to ramp up telehealth, since they will be able to use commercially available products, and not have to stand up HIPAA certified applications.

Expanded telehealth services will be allowed from March 6, 2020 through the end of the public health emergency.

Both the CMS fact sheet and FAQ are available on the CMS website.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


Medicare Advantage Allowed to Expand Telehealth

Medicare Advantage allowed to Expand Telehealth

Written by Ted Kyi

March 10, 2020

This blog is intended to discuss data-driven decision making in healthcare, in particular with risk adjustment and managed care. Given that these days the top story every day is about the novel coronavirus, there are many interesting questions about how telehealth may play a role as people look to reduce the amount of contact they have with others.

With growing numbers of cases and numbers of deaths due to the coronavirus around the globe, questions are beginning to arise about the safety of in-person healthcare visits. These concerns are exacerbated here in the United States by a number of factors, including:

  • Lack of testing
  • Lack of contact tracing of positive patients
  • Possibility of mildly symptomatic or asymptomatic patients who are contagious

For these reasons, many people have discussed avoiding elective procedures and not seeking in-person care unless it is an emergency. This is especially true for seniors, and even more so for those with multiple chronic conditions.

Telemedicine offers an alternative modality for delivering care – a modality which does not carry the risk of infection. Today, CMS released a memo authorizing Medicare Advantage plans to expand access to telehealth. Here is the key passage:

“Medicare Advantage Organizations may also provide enrollees access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes. In response to the unique circumstances resulting from the outbreak of COVID-19, should an Medicare Advantage Organization wish to expand coverage of telehealth services beyond those approved by CMS in the plan’s benefit package for similarly situated enrollees impacted by the outbreak, CMS will exercise its enforcement discretion regarding the administration of Medicare Advantage Organizations’ benefit packages as approved by CMS until it is determined that the exercise of this discretion is no longer necessary in conjunction with the COVID-19 outbreak. CMS consulted with the HHS OIG and HHS OIG advised that should a Medicare Advantage Organization choose to expand coverage of telehealth benefits, as approved by CMS herein, such additional coverage would satisfy the safe harbor to the Federal anti-kickback statute set forth at 42 CFR 1001.952(l).”

The memo also gave permission to change cost sharing for members for COVID-19 services, including telehealth.

“Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for beneficiaries enrolled in their Medicare Advantage plans impacted by the outbreak. For example, Medicare Advantage Organizations may waive or reduce enrollee cost-sharing for COVID-19 laboratory tests, telehealth benefits or other services to address the outbreak provided that Medicare Advantage Organizations waive or reduce cost-sharing for all similarly situated plan enrollees on a uniform basis.”

You can read the full HPMS memo on the CMS website.


Have a question or want to learn more about Matrix's Telehealth offering?

Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.


A Healthy Heart for the Rest of Your Life

A Healthy Heart for the Rest of Your Life

Michelle, a Matrix Nurse Practitioner, recently shared her personal experience with a heart health story and the ways to promote a healthy heart:

My grandmother of 98 years asked that I accompany her to a results visit with her Primary Care Physician (PCP) since I was “almost a doctor” and could help her understand anything if needed. For the record, I am a Matrix Nurse Practitioner and I gladly consented.

We were having a fun conversation when the PCP entered and warmly greeted us as if we were family. He reviewed the results of her lab-work, and then discussed decreasing the dosage on a few medications as she was doing so well.

He discussed continuing her current diet and encouraged her daily walk to the mailbox and back…about 1/4 mile round trip.

He asked if she had questions and spent a few minutes asking about family. He shook her hand and said, “You are such a wonderful person, and have the softest heart I know.”

When we got into the car, she looked angry which is unusual for my grandmother. I asked her what was wrong and she said, “I don’t have a soft heart! My heart is strong as an ox. I don’t think he is a nice doctor to wait until the end of the visit to tell me that!”

I looked at her and said, “He meant that you have a soft spot in your heart for your family, friends and life. He said you were a wonderful person and he meant it.”

She smiled and exclaimed, “He is the nicest doctor I know!”

Whether in the home, mobile clinic or facility, Matrix providers get an opportunity to promote a healthy heart. This opportunity may be presented, or stated in as many different ways as there are providers, but let me leave you with the following:

Help yourself to as much education as you can get. Know what your numbers are, and should be, for your BP, Weight, A1C, and Cholesterol for starters.

Eat a balanced meal that includes a protein, vegetable, starch and carbohydrate. Moderation is key. Be sure to drink plenty of water throughout the day!

Activity should be a part of your daily routine. Start with what you can do, and then do what you can do every day.

Rest and Relax are the hardest to do but most important to plan into your life.

Take time for yourself, family and friends. Share your “soft heart.”


Heart Health Tests — Early Detection Saves Lives

Heart Health Tests — Early Detection Saves Lives

Our heartbeat, strongly linked to our mission at Matrix Medical Network (Matrix), is to create solutions to improve the quality and affordability of health care for the members that are entrusted to us by our health care customers.

Our “heart” longed to reach more members, so Matrix decided to take our “heart health” mission where they live …in the form of Mobile Health Clinics.

One of the unique features of the Mobile Health Clinic to improve quality and affordability of health care is cardiovascular testing. Our Mobile Health Clinics offer a comprehensive health assessment conducted by a board certified provider, who is able to order an Electrocardiogram (ECG) and/or an Echocardiogram (ECHO) for members who have cardiac risk factors. The tests are performed on board the mobile health clinic by a cardiovascular technician in a comfortable setting.

The ECG looks at the electrical activity of the heart and helps the provider determine the rate and regularity of the heartbeat.

The ECHO looks at the pumping activity of the heart, the valves and chambers, using an ultrasound machine. An Interpreting Physician will evaluate the results and a report is sent to the member’s primary care physician (PCP) to support the goals of quality patient care. The PCP assumes responsibility for treating and referring the member to a specialist if indicated.

These two tests are so important to the heart health of the member as they provide a good measurement of how healthy the heart is, or can be, with the proper intervention and treatment that starts with the Matrix team and continues with the member’s PCP or Specialist.

Remember, early detection saves lives!

Matrix mobile health clinics deliver community-based care with enhanced cardiovascular diagnostic capabilities that cannot be done in the home. Learn more about the mobile health clinics.


February is American Heart Month

February is American Heart Month

During the month of February, matters of the heart are often top of mind. From chart-topping songs telling stories of heartbreak to holidays dedicated to the celebration of love, we all seem to be focused on the heart, in a metaphorical sense anyway.

But, behind those multi-colored candy hearts and arrow-wielding cherubs there lies a more serious topic. February marks the beginning of American Heart Month, a federally-designated event that has sought to raise awareness for heart disease and stroke since it was first proclaimed by President Lyndon B. Johnson in 1964.

It’s the goal of organizations like the Centers for Disease Control and the American Heart Association to increase awareness of heart health and lower the risks for heart disease. According to the Centers for Disease Control, heart disease is the leading cause of death for men, women, and people of most racial and ethnic groups in the United States. Both organizations emphasize the importance of regular exams and testing from a healthcare provider.

Within our Matrix Medical Network (Matrix) Clinical Education team, and the Matrix providers in the field, the heart is an organ or pump that sits behind the sternum and sends oxygen rich blood throughout the body with every beat that is electrically initiated. The heart beats at an average rate of 80 times per minute, which is about 42 million times a year.

Thankfully, most of us do not have to think about how or why the heart beats, but ALL of US should be concerned about keeping that heartbeat going strong and healthy for the whole of our lives. Awareness of traditional risk factors, education about heart health and lifestyle modifications can help to mitigate the risk for heart conditions, such as coronary artery disease.

Coronary Artery Disease (CAD) applies to the arteries that supply blood flow to the heart muscle. The diagnosis of CAD indicates that the individual has atherosclerosis or plaque in the coronary arteries. Atherosclerosis builds up and damages the coronary arteries causing platelet aggregation, resulting in a blockage. Atherosclerosis minimizes the blood flow and can lead to ischemia or a myocardial infarction.[1]

Assessing heart health is part of the Matrix Comprehensive Health Assessment (CHA). During the member visit, the Matrix provider spends a portion of the visit asking about issues of the heart…the organ and the vessels in a physical sense that is.

Matrix providers ask questions to assess the member’s risk for heart related disorders, perform a physical exam, and conduct testing. Members are asked if they have a family history of Coronary Artery Disease and when their last Cholesterol screen was done. Providers assess for signs or symptoms that may indicate a heart problem, such as chest pain, shortness of breath, irregular heartbeats, previous surgeries, and history of hospital admissions. Providers on the Matrix Mobile Health Clinic are able to further evaluate the heart using EKG and Echocardiogram testing. The thorough assessment of the whole body system enables the provider to learn more about the overall health of the member’s heart, and to make recommendations regarding following up with their primary care physician or specialist based on these findings.

Follow our posts this month as we address additional topics focused on heart health during American Heart Month.

1 Coronary Heart Disease Risk Factors. (2009, December 2). Retrieved from https://jamanetwork.com/journals/jama/fullarticle/184989


[Infographic] National Nurse Practitioner Week 2019

[Infographic] National Nurse Practitioner Week 2019

Throughout National Nurse Practitioner Week 2019, Matrix Medical Network is celebrating the exceptional professional accomplishments and hard work of Nurse Practitioners (NPs) nationwide and our own clinical champions that serve health plan members across the country.

Chairman and CEO, Keith Henthorne, started off NP Week by recognizing the tremendous impact that Matrix NPs have on members who rely on the quality of care they provide:

“To all of our nurse practitioners, I can’t thank you enough for both the day-to-day work that you do and for all the times you’ve taken that extra step, making sure the members you meet with are well cared for. I know your time with each of them may be brief, but your guidance and influence stays with them long after your visit. You are more than healthcare providers; you are doing important work that touches the lives of those you care for in ways you may never imagine.”

Matrix NPs were also recognized by clinical leadership who shared their gratitude with their teams, and celebrated their accomplishments on the journey of being a NP and the lives they have impacted along the way by providing high quality care to the members we serve. Matrix is also proud to recognize nine NPs that are celebrating their tenth anniversary with Matrix this year!

Dr. Daniel J. Castillo Matrix Chief Medical Officer, Group President Product, Quality and Innovation addressed the integral role that NPs have on the overall healthcare delivery system and recognized our own broad network for their commitment to clinical excellence as shared in a Matrix Press Release.

Throughout the annual NP Week, we are reminded that the service of nurse practitioners deserves recognition and celebration year-round. Learn more about this growing group of highly-trained medical professionals in the infographic below.