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The Voice of Jessica Smith
Risk adjustment has come a long way these past few years. What was once a siloed department deep in Government Programs has turned into an integrated enterprise-wide approach. The evolution of what defines risk adjustment has been transformational for a health plan and created many synergies throughout the organization. Along with the advancement health plans have been making, the Centers for Medicare & Medicaid Services (CMS) has been close behind.
Now that Part II of the Advanced Notice and Call Letter has been released, we are able to get a full view of the proposed policy changes to pave the way for the future. For risk adjustment, the release of Part II did not contain any surprise policy changes. The crux of risk adjustment changes were included in the Part I release. Preliminary industry impacts of the Part I release are outlined in one of my prior blogs at the following link: https://www.gormanhealthgroup.com/blog/the-ever-growing-complexity-of-risk-score-calculation-proposed-changes-for-2019-payment-year/.
The Center for Medicare & Medicaid Services (CMS) released the Advance Notice of Methodological Changes for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model for 2019 on December 27, 2017. This notice reflects the requirements mandated by the 21st Century Cures Act which was enacted by Congress and signed into law in 2016. The proposed risk adjustment changes are an overall positive for the industry. CMS addressed required areas of focus from the Cures Act and the proposed changes will enhance Part C funding for chronic conditions that have been historically under-funded in the past. For example, proposed changes such as these allow health plans more options to provide substance abuse treatments to combat the opioid crisis seen across the nation.
The need to move away from utilizing a person’s social security number (SSN) as their Medicare Health Insurance Claim Number (HICN) has been talked about for years in the healthcare industry in an effort to support fraud prevention. As part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the Centers for Medicare & Medicaid Services (CMS) is now required to discontinue use of the SSN-based HICN to identify Medicare members. Replacing the HICN will be a Medicare Beneficiary Identifier (MBI). The MBI will be a unique identifier, 11 characters long, comprised of numbers and uppercase letters, which is randomly assigned to a Medicare member. CMS will being utilizing the new MBI starting in April 2018. As they transition members from HICNs to MBIs, either identifier is able to be used during this time. The deadline for all members to be transitioned to MBIs is April 2019.
It’s that time of year again when the risk adjustment data submission deadline is fast approaching for Medicare Advantage. Health plans are scrambling to ensure all critical data components are captured, supplemental diagnosis codes are linked, and deletion codes are aligned. The diligence and controls needed to obtain integrity in the information you are submitting can be quite cumbersome. Accuracy and completeness of data submissions are of upmost importance.
The annual Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameter (NBPP) for 2019 proposed rule was released on October 27, 2017. It contains some eye-opening details about the future path of the Affordable Care Act (ACA). There have been many attempts this year to dismantle and drastically alter the course the ACA set out to achieve. The 2019 NBPP proposed regulations display the same message that has been heard all year – to make many changes to the foundational structure and administration process of the ACA.
Now is the time of year when everyone is preparing for back-to-school events and the upcoming holidays, but in that mix is the ever-so-important…Medicare Open Enrollment. Medicare Open Enrollment is an important time to keep or lose valuable members who may have been long-time participants or new to the plan in the last year. There are many reasons member retention is important, but one that is not often talked about it risk adjustment. Risk adjustment has many different types of models utilized to calculate a member’s risk score. The more consistent information you have about a member, the more accurate risk score can be calculated and will allow for an easier understanding of member gaps in care.