Risk Adjustment: Proposed Changes & New Regulations
At Gorman Health Group (GHG), we pride ourselves on having our fingers on the pulse of what continues to be a complex and volatile government programs environment. Whether it is fact or fiction, our clients and our peers look to us to interpret and filter through the official announcements, the breaking news, the propaganda, and the hype.
Being accountable for GHG’s Risk Adjustment division keeps me and our team of consultants quite busy, and just when other departments get to breathe for the holidays, we are inevitably fielding questions and providing “home stretch” support to clients as they prepare for the final submission of risk adjustment data. (In case you missed it, CMS published this memo outlining extended deadlines for data submission.) See full memo here.
If you live in the risk adjustment world, you know this critical business function never really takes a holiday. The Centers Medicare & Medicaid Services (CMS) calendar for data collection and submissions leaves little room for vacations, especially knowing risk scores recalibrate annually and the work to ensure complete and accurate diagnostic data for Medicare Advantage (MA) beneficiaries requires a watchful eye at all times. The reality is, either your hair is on fire, or you just sent the guy in the cube next to you out to refill your propane tank.
Whether we are in the trenches with our clients, or supporting them from afar, GHG is always keeping an eye on what is coming next. So, while you were collecting charts and checking them twice, and making sure your In-Home Assessment vendors were sending information to your Case Management department, here is what has been coming across the wire…don’t worry, we have been keeping tabs on all of the critical activity in the risk adjustment space:
October 28, 2015: CMS announces proposed changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017 which would apply “improved predictive ratios” for full benefit and partial benefit dual-eligible beneficiaries.
November 4, 2015: CMS admits to having underpaid dual-eligible health plans and, in turn, overpays for beneficiaries with low medical costs, sparking concern not only about inequities in payment, but the potential for adverse selection.
December 2, 2015: CMS released an early preview of 2017 MA Ratebook Growth Rates, signaling a hopeful bump in MA plan payments due to a 3.1% increase in traditional Medicare spending in 2017. This is one variable in the equation. Risk adjustment calculation changes and other policy changes will complete the puzzle. More to come on February 22 when CMS releases the Advance Notice for 2017. Stay tuned.
http://www.modernhealthcare.com/article/20151202/NEWS/312029999
December 28: CMS released a Request for Information outlining the expansion of Medicare’s Recovery Audit Program in an effort to identify instances where Medicare is overpaying.
http://www.modernhealthcare.com/article/20151228/NEWS/151229937
January 14, 2016: The Medicare Payment Advisory Commission (MedPAC) voted to pass recommendations which would change how MA plans are potentially paid, potentially saving CMS $5 billion and revealing its position on In-Home Assessments and Star Ratings Quality Bonus Payments.
http://www.modernhealthcare.com/article/20160114/NEWS/160119925
January 22, 2016: This one has a bit of a political spin to it, but we thought it was worth reporting. AHIP released a funded analysis conducted by Avalere Health, finding the risk adjustment model used by CMS “lowballs” the cost of treating chronic conditions such as depression, osteoarthritis, chronic pain, and rheumatoid arthritis by millions, and, in some cases, billions of dollars.
http://www.modernhealthcare.com/article/20160122/NEWS/160129948
Just like our consulting services and our analytics solutions, we assessed the current state of the Medicare risk adjustment industry, collected our findings, and delivered meaningful, actionable information which will keep our clients and readers informed and prepared for what lies ahead in 2017.
A more in-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created whitepaper.
For additional questions and inquiries about how GHG can support your organization’s risk adjustment programs, please contact me directly at dweinrieb@ghgadvisors.com.
Resources
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