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The Voice of Jessica Smith
Risk adjustment audit season is upon us. Some health plans are already in the thick of retrieving charts and starting reviews. Whether it’s a Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit or a Health and Human Services (HHS)-RADV, one thing is true: being prepared is a must!
Risk adjustment at its highest form is nothing more than a calculation. The unique processes surrounding the operations to ensure accuracy of the calculation can be complex. The processes developed and utilized throughout most organizations are relatively similar, however, they are often times misaligned in their approach to operationalize these processes, in turn adding little value or even increasing audit risk. Good strategy and planning with poor execution and oversight lead to an inaccurate risk score calculation overall.
The Department of Health and Human Services (HHS) Notice of Benefit and Payment Parameters (NBPP) for 2019 final rule was released on April 9, 2018. It has been a rocky road since the beginning for the Affordable Care Act (ACA). Over the past few years, the healthcare industry has been struggling to find balance in order to provide affordable healthcare for all. Many issuers have opted not to offer Qualified Health Plans (QHPs) in order to avoid negative financial repercussions due to market unpredictability. At its highest, there were 252 issuers participating on the Federally-Facilitated Marketplace (FFM) in 2015. This year, that number has decreased to 132 issuers.
The Centers for Medicare & Medicaid Services (CMS) released the Final Call Letter on April 2, 2018. The Call Letter solidifies some of the proposed changes that were within the Part 1 Advance Notice released on December 27, 2017, and Part 2 released on February 1, 2018. The final 2019 risk adjustment changes were adjusted slightly in comparison to the proposed but are overall a step in the right direction for the healthcare industry.
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.