CMS is Changing the Medicare Advantage Risk Adjustment Model… Will Your 2021 Revenue Be Impacted?

On January 6, 2020, the Centers for Medicare & Medicaid
Services (CMS) released Part I of the 2021
Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates
and Part C and Part D Payment Policies
(the Advance Notice), which contains
key information about proposed updates to the Part C CMS-Hierarchical Condition
Categories (HCC) risk adjustment model and the use of encounter data.

the past several years, CMS has released the Advance Notice in two parts due to
requirements in the 21st Century Cures Act, which mandated certain changes to
Part C risk adjustment.

1 of the Advance Notice announced a major change to the way that CMS will
calculate risk scores in 2021:

  • Encounter data (i.e., EDS) submissions will comprise 75% of a Medicare Advantage (MA) plan’s
    risk score using the 2020 CMS-HCC model

    • The
      2020 model complies with the 21st Century Cures Act, adding certain mental
      health diagnoses and including an adjustment for members with multiple HCC conditions
      known as the Alternative Payment Condition Count (APCC model)
  • RAPS data submissions will comprise 25% of the MA plan’s remaining risk score using the 2017 CMS-HCC

this change, CMS is continuing its trend of shifting risk-adjusted payments
towards 100% reliance on encounter data submissions. For the 2020 payment year,
the blend is 50% EDS (2020 model) / 50% RAPS (2017 model).

to CMS, the combined impact of the transition to a greater percentage of MA risk
scores calculated using encounter data, fee-for-service (FFS) claims, and RAPS
inpatient records is 0.00%. CMS further states that the transition to the new
model will have a .25% positive impact to RAF in 2021. 

obtaining revenue neutrality or favorability may be difficult for payers who do
not have an adequate data integrity process in place to ensure that all
eligible encounters are being submitted to both EDS and RAPS. A recent study of 2.5
million MA lives led by Pareto Intelligence,
a GHG partner, found that the
transition to 75% EDS submissions in risk score calculations is projected to
result in $23 per member per year (PMPY) revenue shortfall for 2021.

Payers Can Prepare for this Change and Mitigate Potential Revenue Shortfall

Plans should take steps now to determine the impact of the blend and model change to their risk scores and revenue, and mitigate potential adverse outcomes of the risk adjustment changes:

  • Compare 2020 midyear risk scores against 2020 final budgeted risk score. Was this in line with your expectations when you created your risk score goals during CY 2019?
    • Why This Matters: Even though 2020 payments are blended at 50% EDS/50% RAPS, any shortcomings in expected versus actual risk score performance could be magnified by the increased use of encounter data, which is an inherently more complex submission process. A better understanding of performance will give some insight into whether the blend and model change could have an adverse impact on risk scores, particularly when CMS moves to the 75% EDS/25 RAPS% split in 2021. Once you identify any gaps that may exist, you can begin to mitigate the impact of these changes to risk score calculations.
  • Accelerate data integrity and reconciliation operational processes. This reconciliation should be applied to both claims and supplemental data.
    • Why This Matters: As CMS moves towards calculating 100% of risk adjustment payments using encounter data, payers need to evaluate whether current CMS submission processes result in complete and accurate data without filtering or truncating any data that is eligible to be submitted.

      This is also critical for any risk score differences that may exist between RAPS and EDS submissions. If the advanced submission requirements and filtering logic for EDS are causing encounters that would otherwise be accepted by RAPS to be rejected by EDS, you could be leaving money on the table. Payers should evaluate data completeness and accuracy from encounter through to regulatory submission to proactively resolve issues.

accelerated transition from RAPS to EDS is not the only notable change in the
Advance Notice. Be on the lookout for a follow up to this article where GHG
works in tandem with Pareto Intelligence to analyze the
estimated risk score impact of the changes to the risk adjustment model.

For assistance navigating impending changes to the MA risk adjustment model and optimizing your risk adjustment program for success, please contact Jeff De Los Reyes at

OIG Cracks Down on Chart Reviews in Medicare Advantage Risk Adjustment

On December 10th, 2019, the Department of Health and Human Services Office of Inspector General (OIG) released a report, which evaluated how Medicare Advantage Organizations (MAOs) used chart reviews to increase risk adjustment payments for Medicare Advantage (MA) beneficiaries in the 2017 payment year (2016 Dates of Service [DOS]). While the Centers for Medicare and Medicaid Services (CMS) did not completely agree with all of OIG’s findings, they did concur with OIG’s recommendations to provide additional oversight of MAOs.

Additionally, while the OIG study did have limitations, the findings are still highly relevant, and come at a time when CMS continues to push forward with Risk Adjustment Data Validation (RADV) audits to ensure that all diagnosis data submitted to CMS by MAOs is accurate and complete. (The payment year [PY] 2014 RADV audit started last year, and another 2015 RADV recently started.) It is important to note that CMS considers the use of RADV audits as the best approach for ensuring MAOs are documenting diagnoses appropriately.

Important Details on Risk Adjustment in Medicare Advantage

CMS risk-adjusts payment using diagnoses submitted by MAOs and pays a
higher capitated payment to MAOs that report a higher level of illness burden
for members. MAOs submit these diagnoses through two submission processes: Risk
Adjustment Processing System (RAPS) and Encounter Data Processing System

To be eligible for risk adjustment, a diagnosis must be documented in a
medical record as a result of a face-to-face visit. Currently, CMS allows plans
to submit chart review diagnoses either linked or unlinked. A linked chart review
diagnosis can be traced back to a previously accepted service record or
original encounter. An unlinked chart review diagnosis occurs when MAOs cannot
identify the specific service or encounter associated to the diagnosis. It is
important to note that, at this time, CMS still considers both linked and
unlinked chart reviews as acceptable methods to submit risk adjustment-eligible

Key Takeaways from the OIG Report

Below are some of the major findings in the OIG evaluation of chart
reviews in MA:

  • MAOs almost always used chart reviews to add, rather than to delete, diagnoses. Over 99% of the chart reviews in the OIG study added diagnoses.
    • In CMS’ response letter to the OIG study, CMS did state that, “chart review records are intended for the submission of additional diagnosis codes for risk adjustment. Based on their reviews of medical records, MAOs may also use chart review records to delete previously submitted diagnoses codes that are not supported by those medical records; if they identify unsupported codes, MAOs must delete them.”
  • Although limited to a small number of beneficiaries, almost half of MAOs reviewed in the study received payments from unlinked chart reviews where there was no single record of service being provided to the beneficiary. Furthermore, more than one-third of MAOs linked some, but not all, of chart reviews to original service records.
  • CMS estimated that $2.7 billion in risk-adjusted payments were paid for chart review diagnoses that MAOs did not link to any service provided to the beneficiary. However, the OIG study did not take into account the blended payment model (RAPS/EDPS) with this calculation. The actual value of these payments using the blended model is approximately $675 million.

Implications for Medicare Advantage Organizations

As a result of these findings, OIG made three recommendations to CMS
with which CMS agreed. Below are the recommendations along with implications
for MAOs:

Provide targeted oversight of MAOs that received risk-adjusted payments resulting from unlinked chart reviews for beneficiaries with no service records in the 2016 encounter data.

MAOs that submitted chart review diagnoses, but did not submit any other
service records for the beneficiary, were reimbursed by CMS to care for the
member; however, no evidence of services or treatments that MAOs provided to
these beneficiaries was submitted to CMS.

What MAOs Can Do:
Evaluate overall data integrity and perform an in-depth analysis of the process
for submitting complete RAPS and encounter data to ensure that all appropriate
service records are reported to CMS. Improved data quality can also improve the
rate of linking chart review diagnoses to original encounters. This is
especially important as CMS
continues to rely on encounter data more than RAPS
submissions for risk
adjustment payments, which was announced the
latest CMS Advance Notice.

Conduct audits that validate diagnoses on chart reviews in MA encounter data. 

Implications: 2015
was the first year in which CMS started to use encounter data to calculate risk
adjustment payments. CMS has stated that they will include diagnoses from chart
reviews in RADV audits.

What MAOs Can Do:
Perform an over-read validation audit on a sample of chart review diagnoses
submitted to CMS that resulted in payment. If any chart review diagnoses fail
validation, MAOs can submit these as deletes to CMS (even if the period is
closed). In general, MAOs should consider the use of chart reviews to submit
both adds and deletes to CMS—i.e., incorporating a “two-way look” for HCCs,
especially on claims.

Further, MAOs should implement an HCC compliance program
and/or a rigorous QA/over-read process as part of an overall risk adjustment
strategy to ensure that diagnoses from encounters, as well as diagnoses from
chart reviews, are accurate and valid. This is especially important for MAOs
who use a third-party vendor for chart review coding.

A comprehensive compliance program must include ongoing
evaluation throughout the year that identifies and validates diagnoses that are
at high risk of being submitted erroneously without the proper documentation,
as well as the performing of outlier audits.

Reassess the risks and benefits of allowing chart reviews that are not linked to service records to be used as sources of diagnoses for risk adjustment.

Implications: At
this time, CMS will continue to allow the use of chart review records both
linked and unlinked as sources for risk adjustment payment. However, this may
not always be the case, which would result in a reduction of payments for MAOs
that submit a high number of unlinked chart review records.

What MAOs Can Do:
As best practice, MAOs should continue to submit both linked and unlinked chart
review records to CMS. The linking of chart review records to the original
encounter can be complex and burdensome to an organization’s submission process
infrastructure. However, MAOs should evaluate current chart review processes,
specifically around the linking process and logic, to identify whether the linking
logic is too stringent and to submit more chart review diagnoses as linked
records. As an example, MAOs can identify cases where previously unlinked chart
review records can be linked back to the original encounter by analyzing the
use of rendering versus billing provider and DOS ranges in the linking process.
If MAOs use a third-party vendor for chart review, there must be adequate
vendor oversight and QA of the submitted codes.

Lastly, MAOs should start to implement and invest in
prospective provider programs (including concurrent chart review) to capture all
relevant member diagnoses at the point-of-care and ensure data is both
documented in the medical record and submitted  appropriately on the claim/encounter that is
submitted to the health plan.


Historically, MAOs have used risk
adjustment programs like chart reviews to enhance risk-adjusted payments from
CMS by supplementing submissions to CMS with more complete diagnoses data from chart review programs. MAOs should
evaluate current risk adjustment programs to ensure payments from CMS are both
complete, and more importantly, accurate. Accuracy in risk adjustment should
include “looking both ways” by using chart reviews to add and
verify/delete diagnoses from previously submitted encounters.

Please contact Jeff De Los Reyes, leader
of Risk Adjustment and Healthcare Analytics Advisory practice at Gorman Health
Group, at
for more information.

Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On December 30, 2019, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Parts C & D Enrollee Grievance, Organization/Coverage Determination and Appeals Guidance, which became effective as of January 1, 2020.  Noteworthy changes are summarized below:

  • In Section 10.5.3, the guidance was expanded to include more detail about verbal notifications. This section details when and under what circumstances the verbal notification is considered delivered, what defines a successful verbal notification (e.g., speaking with the person that submitted the request or leaving a voicemail message), and the appropriate steps to take if written notice is required along with verbal notification. CMS also deleted subsection 10.5.4: Good Faith Effort to Provide Verbal Notification, which was a new section introduced in the February 2019 version of the Guidance. There is a notable revision to guidance for a favorable decision that a plan “may” deliver written confirmation of its decision after initially providing verbal notification of the decision. This is a change from the 2019 guidance indicating the plan “must” deliver written notification. (See updated Section 40.8.)
  • Throughout the Parts C & D Guidance, CMS revised existing requirements to now include Part B Drugs.
  • Section 40 (Coverage Determinations, Organization Determinations [Initial Determinations] and At-Risk Determinations) has several significant updates:
    • There is a more detailed description of the process for requesting a Part C pre-service organization determination or Prior Authorization (PA). CMS provides clarification that Medicare Advantage (MA) plans should be prepared to address medical necessity as required in these scenarios. (See Section 40.1.)
    • There is a new Part D provision that applies to circumstances where a plan is asked to waive a PA or other Utilization Management requirement. Updated language provides for tolling of the timeframe by up to 14 calendar days after the receipt of a request to receive the supporting statement. (See Sections 40.4 and 40.5.3.)
    • Also noted are new Part D notification timeframes surrounding Exception Requests. In previous guidance, plans were instructed not to keep requests for supporting statements open indefinitely. This language is deleted in the updated guidance, and in its place, CMS outlines specific new timeframes for enrollee and prescribing physician (as appropriate) notification of plan decisions for both expedited and standard requests, and includes notification timeframes for circumstances when the supporting statement is not received with the 14 calendar day timeframe.
    • CMS has included Part B Drugs in the decision timeframes (favorable, partially favorable, or adverse) as well as processing timeframes (72 hours for standard requests for Part B Drugs and 24 hours for expedited). CMS also clarified that requests for Part B Drugs and payment timeframes cannot be extended.
  • Section 50 Reconsiderations and Redeterminations (Level 1 Appeals) contains a number of updated clarifications to existing requirements. Most noteworthy changes are the provisions for adjudication timeframes for Part B Drugs. 
  • CMS clarifies Health Care Pre-Payment Plans (HCPPs) are not regulated by Section 100 (Provider Notices in Hospital, SNF, HHA and CORF Settings [Part C Only]) and clarifies that HCPP enrollees must follow Original Medicare immediate review processes.
  • The Medicare Managed Care Appeals Process Overview for Part C (Appendix 1) is amended to include timeframes for Part B Drugs in both the standard and expedited processes. Also, for both Parts C and D Process Overviews, the “Amount in Controversy” (AIC) is increased to $170 at the Administrative Law Judge (ALJ) Hearing stage. The AIC is also increased at the Federal District Court stage to $1,670.

Plans should carefully review the
updates and incorporate the numerous changes to existing plan policy.

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GHG assists plans in implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

The OEP Is Almost Upon US! Are YOU Ready?

January 1, 2020,
Medicare Advantage (MA) enrollees have a one-time opportunity to switch their
plan, similar to a grace period, and the opportunity ends March 31. Both new MA
enrollees and existing enrollees have the ability to switch plans. This is a
chance for MA plans to win and lose enrollment! To make sure you are not on the
losing enrollment side, here are a few ideas in which to invest resources and
budget before the upcoming Open Enrollment Period (OEP). Per the Deft research
2019 OEP study, “Almost 75% of the OEP
switchers had also switched during AEP!”
GHG expects to see more movement during OEP this year as Medicare
beneficiaries are more aware of the opportunity.

Services and Member Communications Need to Be the Stars of OEP!

Member communication
interactions (either verbal, written, or in person) could either break or win
you the OEP. You still have time to review your welcome interactions with both
new and existing members to ensure they are best in class. You may want to have
member events this year so new and existing members understand the 2020
benefits – and if you have great news for them, you want to make sure they hear

The goal is to ensure
every new member knows what to do January 1 and to have multiple touches that
educate, welcome, and engage members about their new MA plan. The earlier you
start this process, the better. You do not want buyer’s remorse occurring at
any point from the sale through the end of OEP. Existing members need to be
educated about any changes in benefits, and if your data is talking to you, you
will have a list of members who need “real” hands-on member service touch points.

Basic awareness of
online portals and any mobile apps offered by the plan also correlate strongly
to plan loyalty. Loyal members are more likely to participate in plan wellness
programs, which can help with cost containment and utilization.

In addition, when was the last time you really looked at
the communications going to your members?

  • Are
    you communicating too much or not enough?
  • Do
    the communications have the same tone and messaging throughout? Or are they
    just recycled from year to year?
  • Has
    the Member Services team received training lately to make sure they are
    reinforcing the tone and messaging you want your members to hear and feel?
  • Do
    they know the 2020 benefits and what benefits to make sure members know about?
  • Do
    you listen to Member Services calls to ensure you are providing the member
    experience you portray in your advertising and communications?
  • Do
    you take member feedback into account in designing member materials?

Usefulness of member
materials in regards to understanding coverage and benefits is strongly
associated with loyalty. Now is the time to reassess how you are communicating
with your members and make certain you are maximizing your opportunity.

Cannot Be Forgotten

Health plans are unable to market the OEP opportunity but
do have the ability to market the following:

  • Branding
  • New
    to Medicare
  • Education

Although you may not
have much of a budget for marketing during the first quarter, you can utilize
it effectively. Make sure you are advertising in January and the last few weeks
of March. If you have educational events, advertising them digitally or though
radio will help bring additional awareness to what your organization does for
its members. Most plans have a very robust “New to Medicare” budget already, but
you may want to invest in some freestanding inserts in January or March, amp up
your digital advertising, and/or advertise on TV. Utilize branding during this
time since it puts your name in the market during the OEP. Whatever you have
the resources to do, make sure you are strategic in your efforts to make it

It Is
Not All About Winning Enrollment

At Gorman Health Group, we are hearing many clients talk about gaining enrollment during the OEP but not so much about the possibility of losing membership. Your goal should be to ensure you have everything in place for this OEP to make certain you are on the winning side of OEP and are not giving up your membership to another MA plan that made sure they strategically invested in this opportunity!

For more information about the OEP opportunity and ways you can set up your team for success, contact us at or

2020 Readiness Checklist

On October 3, 2019 the Centers
for Medicare & Medicaid Services (CMS) released the 2020 Readiness
Checklist highlighting critical operational and contractual requirements for
Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs),
Medicare-Medicaid Plans (MMPs), and Cost Plans. 
The readiness checklist is released annually and, when used as a
“self-assessment,” can be an effective tool for validating organizational
compliance with Annual Election Period (AEP) and 2020 plan coverage requirements.  With this self-assessment, the organization
will have both a working knowledge of their state of readiness as well as a roadmap
for process improvements.  It’s important
to note that organizations are required to identify risks and notify their CMS account
manager(s) and should anticipate follow-up discussions on those areas of focus.

Plan Sponsors should carefully
review the checklist for regulatory changes and updates that may have occurred
since the 2019 checklist’s release.  Remember,
this checklist is intended as a summary of the critical requirements.  Plans should refer to all new guidance,
memos, Final Rules, and the Call Letter for the detailed interpretation of CMS

A few examples of focus areas that may be new or expanded
for 2020 include:

  • Precluded
    Providers and Prescribers
    - For 2020 CMS has expanded on the expectations
    for managing precluded providers and prescribers.  In addition to requiring beneficiary notices:
    MAOs/Part D Sponsors must deny payments for a health care item or service,
    reject the pharmacy claim, or deny the beneficiary request for reimbursement
    when the prescribing individual is on the Preclusion List. 
  • Timeframes
    for adjudicating Part B Drug Requests
    – The Medicare Advantage (MA) and
    Part D Drug Pricing Final Rule (CMS-4180-F) issued in May 2019 introduced new,
    shortened adjudication timeframes for Part B drugs. MAOs must ensure requests
    are adjudicated and favorable decisions are effectuated in accordance with the
    new guidelines.
  • Medicare
    Plan Finder Data (MPF)
    – For 2020 Part D Sponsors should ensure access to
    the Health Plan Management System (HPMS) Part D Pricing File Submission Module
    for both Part D pricing file submission and quality assurance (QA) validation
    results.  The updates and announcements
    previously available on the MPF Communications Website are now posted in the
    module’s Documentation section.
  • Medicare
    Marketing -
    Updates to the Medicare Communications and Marketing Guidelines
    (MCMG) will impact marketing and communication materials and activities. Plan
    Sponsors must ensure the respective materials comply with the most current
  • Prescription
    Drug Event (PDE) Requirements
    – Part D Sponsors must ensure submission of
    data and information necessary for CMS to carry out payment provisions are
    submitted through the Prescription Drug Front-End System (PDFS) and processed
    by the Drug Data Processing System (DDPS). 
    Details about what is required to become certified to submit data, along
    with guidance on data submission and other resources, is available on the
    Customer Service Support Center (CSSC) website.
  • Coverage
    Gap Discount Program (CGDP)
    – CMS expects Part D Sponsors to be familiar
    with their responsibilities to participate in the CGDP, and provides
    information about the CGDP portal, onboarding training and CGDP Portal Sponsor
    User Guides available from the website in the Reference

GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. This is especially important for Plans new to the market in 2020. Contact us today for additional information.

Blending Network Strategy & Product Strategy

As more and more health systems and provider organizations successfully manage the shift from volume-based patient care to value-based population health management, health plan strategic planning should be blending network strategy with product strategy as a key factor in the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay-for-performance and upside risk arrangements and, as providers have seen their margins narrow and plateau, they are more willing to step out into more advanced risk-sharing deals, plans have had to adapt and move beyond simple incentivizing for behavior change. Systems that have ventured into managing downside risk and percent of premium arrangements and have been successful have an appetite for more. Certainly, moving up the food chain from a provider to a payer has been a topic of conversation among Chief Executive Officers of large integrated delivery systems. They have worked hard to align referral networks and build physician trust, develop relationships with diverse community support organizations, forge a strong brand recognition in their local communities, and negotiate contracts with health plans that have met and exceeded care and cost containment goals.

Historically, health plans have based a large majority of their decisions regarding expansion areas on the financial feasibility of the markets. Understanding the desire and direction of health systems in general coupled with the alliances plans have worked hard to develop in their current markets, the trend has been to include a network assessment as part of the new market feasibility. Knowing the local players, their appetite for risk, hospital alliances, the Accountable Care Organizations (ACOs) in the market, along with modeling the potential partners against Centers for Medicare & Medicaid Services (CMS) network adequacy standards, can play a significant part in the success or failure in any expansion market.

As we have met and strategized with
provider systems from their baby steps into pay-for-performance incentives to
negotiating their first risk deal, there has been, and still is, a strong
reliance on health plans to set clinical pathways and benchmarks. From the
provider perspective, the reporting, transparency and willingness to share in
the financial successes with the plan partners, is a key consideration in who
to collaborate with.  Systems are starting
to explore the administrative support organizations available and realize stepping
out to become their own health plan doesn’t seem as scary as it may have five
years ago. From the plan perspective, the need to partner with providers and
health systems with a depth of understanding in risk adjustment and Stars along
with the clinical skill set, and often non-clinical support services, to truly
provide a holistic approach to patient care has never been more critical to
success.  The directive for potential new
network adequacy requirements and more tele-health options will allow room for
plans to become even more innovative with their benefits. The ability to blend
network strategy and product strategy will likely be evident of how successful plans

For plans and providers, knowing
your local healthcare market, who the key stakeholders are, and keeping open
communication will be paramount to the development of a strategy that puts you
ahead of your competition.

Three Ways to Retain Your Members for 2020

It’s the Annual Election Period (AEP) and now
is a really difficult time to turn your thoughts away from what’s right in
front of you, but a strong retention program can be the difference between
achieving your enrollment goals or missing them.  Member retention is key to long-term
success.  Net growth does not happen with
new sales alone, but with a careful balance between new sales and the retention
of members once they have enrolled.  The
following are three recommendations to help you think through opportunities for
your retention plan.

  • Onboarding new members and developing a year-long engagement strategy is crucial today. Per the Deft research 2019 (Open Enrollment Period) OEP study “Almost 75% of the OEP switchers had also switched during AEP!”  And GHG expects to see more movement during OEP this year as Medicare beneficiaries are more aware of the opportunity.  Developing a structured onboarding strategy that begins with the agent (whether it is a sales agent or telephone representative) is important.  In addition, developing a Welcome package and Welcome calls that occur well before the new member is accessing benefits is important.  During these communications, you need to capture how each member wants to be communicated with going forward to find the best way to interact on a one-to-one basis. 

Today there are multiple benefits (all with different rules and access points) that are offered by vendors and not the health plan which can cause confusion. This doesn’t include the plan rules, provider issues, and the complexity of some of the pharmacy benefits offered today.  Developing a year-long multi-channel education strategy for new members is key to engagement.  This strategy should be more heavily weighted to the first three months during the OEP.


  • Many times GHG asks the question “How do you educate members about new benefits, especially new additions to the Plan or decreases in premium and copays?”  In most cases the response is the Annual Notice of Change (ANOC).  GHG considers this a government document not a member communication.  While there is advertising to increase membership, many times the effort is not made to let members know what you are doing for them.  Communicating to your members about what you do right and the improvements you are making to benefits, premiums, providers, and even better operational improvements can help the member to ignore the AEP or be persuaded by agents or the advertising in the marketplace.  Many times this can be done by a variety of touch points such as outbound phone calls, newsletters, emails, your website, member meetings, or digitally to make sure the member has reinforcement in a variety of different communication channels.
  • Developing a specific retention strategy to target those most likely to leave.  Typically, we know those who are in a Medicare Advantage (MA) plan less than three years and members with the little to no utilization or engagement are most likely to leave, but does that hold up for your MA plan?  Profiling members most likely to leave and investing in a retention strategy to engage these members will more than pay for itself.  Also, it is important to measure this and understand what the potential return on investment is for these efforts.  As budgets are constantly under scrutiny, you need to understand what these investments in retention save you in the long run.

These are just three tips to get you started on your way to increasing membership, just by keeping the members you have!  If you have questions or want more information about how you can develop a member retention or engagement strategy reach out to me at or call me at 215-499-1417.  Call today – it is not too late to get this done before 2020!

Compliant Coding and Documentation: Minimize Compliance Risk with CMS through HCC audit programs

Was your plan selected for this year’s Medicare
Part C Contract-Level Risk Adjustment Data Validation (RADV) audit of 2014
dates of service?  Have you participated
in a Department of Health & Human Services (HHS) Office of Inspector
General (OIG) audit related to risk adjustment submissions? Does your plan
participate in the Affordable Care Act (ACA) individual and small group
marketplace?  Are you a provider who was
asked to supply records for any audit related to risk adjustment and/or are you
in a risk bearing agreement with one or more payers for Medicare Advantage (MA),
ACA, or Medicaid?

If you answered “yes” to any one of
these questions, you know what a critical role documentation and coding plays
in a risk adjustment program.  Even plans
and providers who answered “no” to any of the questions should have a program
in place to mitigate compliance risk when it comes to the accuracy and
integrity of data being sent to CMS.  CMS
requires health plans to submit accurate and complete risk adjustment data that
are fully supported in the medical record with adequate evidence that a
condition exists and is being managed.  A
comprehensive, year round Hierarchical Condition Category (HCC) audit program
should be an important part of any risk adjustment program in order to mitigate
risk with CMS in the future. 

well-rounded HCC compliance program should include the following components:

  1. Coding policy due diligence – Review of internal coding guidelines
    and policies and procedures of coding practices (for plans with internal coding
    teams).  Review of vendor coding policies
    and performance service-level agreements (SLAs) included in coding contracts.
  • Mock RADV – Replicate the entire RADV process
    from analytics required to identify the source of the HCC for validation to
    creating the provider chase file and requesting the medical records for
    validation of the HCC.  A RADV requires
    the coordination of multiple business units to meet the strict and constricted
    timelines of CMS.   RADV preparedness
    will ensure all business units know their role in the RADV and can execute
    effectively if your plan is selected.
  • Targeted Diagnoses Audit – Identify potential “high risk” diagnoses
    codes submitted on claims and validate these against the medical record to
    ensure that sufficient documentation exists to support these diagnoses.  Examples include ”single occurrence” diagnoses
    where there is only one instance of the diagnoses submitted for a member in a
    calendar year by only one provider.
  • Provider Outlier Audit – Identify providers who have a
    significantly higher prevalence of members with specific chronic conditions
    than your plan’s average, based on their claim submissions.  Also, look at the pattern of diagnoses being
    submitted by provider specialty types and identify outliers or mismatches.  For example, some chronic conditions are more
    suited to be assessed and managed by certain specialists versus other specialty
    types.  Payers can mine this data and
    pull medical charts for these provider outliers to review the medical record
    against the claim submission.
  • Vendor over-reads
    Most payers or providers outsource some or all of their retrospective
    chart reviews or prospective assessment programs to external coding
    vendors.  These vendors then submit the
    supplemental diagnoses for submission by the health plan.  Typically, coding vendors have performance SLAs
    to ensure 95% or greater accuracy based on the vendor over-read of a sample of
    their charts. Payers should also perform an independent review of their coding
    vendors to ensure the accuracy of the diagnoses being submitted.
  • Detailed and technically sound delete
    process infrastructure
    :  In any instance where a diagnoses is found to
    have insufficient evidence in the medical record, payers are obligated to
    delete the diagnose codes from a CMS submission.  It is important for payers to have a thorough
    understanding of their delete process to ensure they are not over-deleting
    diagnoses codes that could lead to potential negative financial
    consequences.  Prior to any delete
    project resulting from an internal audit, plans need to examine the potential
    financial implications that might affect their budgeting and accrual process.
  • Provider
    feedback and Clinical Documentation Improvement: 
    any diagnoses are found to be unsupported in the medical record, it is
    imperative that providers are educated on the importance of proper
    documentation and coding, to avoid the re-occurrence of the submission of any
    unsupported diagnoses.  Plans should have
    a robust provider feedback loop so that providers are continually kept abreast
    of how they are documenting and coding, and if needed deploy a clinical
    documentation improvement plan.

Risk adjustment plays a critical role in
revenue generation for payers who participate in government sponsored programs
such as MA.  Putting in place a risk
adjustment clinical documentation compliance program will enable payers to
avoid financial risk in the case of a potential MA RADV extrapolation and/or an
ACA marketplace adjustment following an Internal Validation Audit (IVA).

CMS HCC RADV audits are here to stay and
plans that participate in the ACA marketplace are already familiar with the IVA
requirements.  Many plans have also been
targeted for an OIG audit.  CMS is
looking to use these audits to recoup improper payments to plans which may have
a significant financial impact.  Plan and
provider executives at all levels - including the Chief Executive Officer (CEO),
Chief Financial Officer (CFO), and Compliance Officers - should evaluate what
programs they have in place to mitigate future audit risks.

Whether you already have a risk adjustment compliance program in place and need an independent review of these programs against best practices or are thinking about designing and implementing a program, we can help.  For additional questions and inquiries about how GHG can help, please contact me at

New Membership Preparation From a Clinical Perspective

How do plans get ready for new membership as the new
enrollment period starts?

When you are trying to plan for the future at times it is
best to look back at the past….past data, past experiences, trends and your past
mistakes as well.

As AEP rolls around it’s time to look back at the clinical
picture of plan year 2018 data. If you are keeping the same service areas, or
if you are entering counties with like populations, what did your last plan
year’s data tell you? Did you anticipate the population attributes that contributed
to increased utilization costs?

One exercise to consider is to isolate all of the members
who were new to your plan last year, by county, and look back at their
inpatient, pharmacy and outpatient specialty physician use. Then take this data
and categorize by disease state or diagnosis, age/gender bands and plan type.

Consider to then ask the following questions:

  • Did we analyze, on a first quarter/monthly
    basis, the new Rx fills for this new membership for clues to the member early
    care management intervention?
  • Did the care management team reach out to and
    successfully engage the member in care management strategies?
  • Did the care management team identify any
    additional information that could have been beneficial for prevention of
    hospital admissions and if so, how was the information used to influence member
    behavior?  Was the information shared
    with the PCP?  ? (hopefully to the PCP)
  • Was the comprehensive medication review conducted
    timely and did the review reveal new care management clues?
  • Did we see patterns of underutilization on the
    provider side based upon the type of prescriptions filled?
  • Did we see a member with high utilization of a
    specialty provider without establishing a PCP?

Taking into consideration your past plan year data trends,
especially with similar populations in the same service area/subsidy
classification and benefit structures can give you clues of what may be in your
future for managing new members  from a
clinical program perspective.

If you have the opportunity to use a tool that prospectively
predicts social determinant of health attributes based upon consumer behaviors,
this will be a great data overlay to the above.

Many plans miss opportunities with new members because,
well, they are new and if they don’t hit the hospital doors or have high claims
volume early on, they stay on the outside of what care support or interventions
are possible to manage their care.  To
help prepare for the upcoming year, we recommend that plans start analyzing
member information early on, and then ongoing to identify ways the plan can
help members use the benefits and network to their benefit and your cost


In the Midst of AEP…Don’t Lose Sight of the Upcoming Application Season Compliance Solutions

mid-October, CMS will release the online Calendar Year 2021 Notice of Intent to
Apply (NOIA).  The NOIA must be submitted
to CMS by November 12, 2019 if organizations plan to submit an application for
the 2021 plan year, either for a new contract or contract expansion, including
the following:

that time again…time to begin marketing for the upcoming plan year and prepare
for sales and enrollment activities during the Annual Election Period
(AEP).  With all that entails, it can be
easy to forget about other upcoming important dates on the Centers for Medicare
and Medicaid Services (CMS) calendar.

  • New Medicare
    Advantage (MA) or Prescription Drug Benefit (Part D) contract
  • Offering a new
    product type
  • Expanding the
    service area
  • Adding
    prescription drug benefits (Part D) to an existing contract

can organizations be best prepared?  It’s
not too late to conduct a feasibility study to assist in the ‘go/no-go’
decision.  A network analysis should also
be completed to determine any potential adequacy issues or gaps.  Remember that filing the NOIA with CMS only
informs them of the Organization’s intent to apply, it does not require that a
formal application be submitted.

Gorman Health Group can assist in all phases of the application process including the feasibility study, network analysis, and application completion/submission.  We have a long history of successful submissions and support.  Contact us today to discuss how we can best support your Organization.

GHG cannot only assist with your application filing but can also project manage the entire process?  Contact us today for more information.