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The Voice of Jessica Smith
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.
Controversy is brewing in the healthcare insurance community since the much anticipated Medicare Advantage (MA) analysis due to be released at the AcademyHealth annual research meeting was cancelled. Today, MA plans enroll more Medicare-eligible beneficiaries than Fee-for-Service (FFS). The desire to understand the needs and services these beneficiaries have and are receiving is great.
Last week, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 Health and Human Services Operated Risk Adjustment Data Validation (HHS-RADV) would be conducted as a pilot year in the same aspect as the 2015 HHS-RADV. This announcement came two days after the final risk adjustment data submissions were due to be submitted to the EDGE server for 2016 dates of service.
The comments have rolled in, and the concerns regarding the transition from Risk Adjustment Processing System (RAPS) to Encounter Data Processing System (EDPS) have been heard. The final Medicare Advantage Call Letter was released on April 3, 2017, and it contained a surprise on every page that was turned.
Even though the year has just begun, the healthcare industry is looking ahead to what the next four years has in store. The Centers for Medicare & Medicaid Services (CMS) released its 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter (“2018 Draft Call Letter”) on February 1, 2017. As a whole, the 2018 Draft Call Letter had minimal updates, however, there were important impacts to risk adjustment.
Risk adjustment has been around for many years now, but the terms “data governance,” “data integrity,” and “data definitions” were not mainstream until recently. Why is that?