The policy analysis and guidance you need by the experts you trust, daily.
- After Hours
- Agent Oversight
- Brain Food
- Health Insurance Exchanges
- Part D
- Performance Optimization
- Policy & Health Reform
- Prospective Evaluations
- Provider Relations
- Risk Adjustment
- Sales & Marketing
- Star Ratings
- Alan Mittermaier on MA and Part D Proposed Rule Increases Plan Flexibility, Reduces Regulatory Burden
- Sharon Willliams on A New Source of Capital for Star Ratings and Clinical Innovations
- William on Will Trump and Price Pull Out the Scalpels for Star Ratings?
- Bobby on January Release of the Draft MMG – Perfect Timing
- Pam Lassila on Best Practices and Common Conditions of Audit Preparation
Topic: Risk Adjustment
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/.
On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Advance Rate Notice (Part II) and Draft Call Letter. CMS estimates an expected increase of 1.84% to payments in 2019. CMS says its estimates do not reflect underlying coding trend, which it expects to increase risk scores by 3.1% in 2019.
As 2018 and Year 2 of the chaotic Trump Administration kick off, trying to predict what will happen in Medicare, Medicaid, and the Affordable Care Act is as challenging as ever. It’s a midterm election year with terrible headwinds for the GOP, so the legislative calendar is abbreviated, and partisan rancor will peak. That makes it less likely Republicans will get to do much damage but also more likely they will try to serve up red meat for their base, like a return to “repeal and replace.” Congressional leaders, fresh off their billionaire bailout tax bill, are already talking about taking up “reform” (aka cuts) of Medicare and Medicaid and other social welfare programs. The only thing that is certain is 2018 will be another battleground year for government health programs.
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.