Risk Adjustment Recap & Keys to Success
The 2016 Final Call Letter released on Monday, April 6, confirmed proposed rulings highlighting the following categories:
- End the Blend; For payment year 2016, CMS will only use the 2014 HCC Risk Adjustment Model.
- Coding Pattern Adjustment; CMS has increased the adjustment factor for MA coding pattern differences by 0.25 percent, the lowest amount possible under the statute. As such, the updated adjustment factor for 2016 is 5.41 percent.
- Encounter Data as a Source for 2014; CMS will apply the 90/10 rule until they implement “risk adjustment using Medicare Advantage diagnostic, cost, and use data,” meaning until they have recalibrated the model using MA encounter data.
- ICD-10; CMS will not accept or process ICD-9 codes for risk adjustment for services with dates of service beginning October 1, 2015.
- RXHCC Model; The model has been updated to reflect the 2016 benefit structure, updates to the data years used to calibrate the model, and clinical updates to the diagnoses included in some prescription drug hierarchical condition categories.
- In-Home Assessment; Adopt a core set of components and best practices for In-Home Assessments, Track subsequently provided care: In CY 2015, CMS will track and analyze care provision following in-home visits.
These are the facts. Gorman Health Group is focused on providing you the tools in order to succeed and implement an enterprise-wide risk adjustment model. Based on The Centers for Medicare & Medicaid Services (CMS), collaborative partnerships between health plans and providers will ensure optimum performance outcomes for revenue, medical management and quality. Is your organization currently assessing, enhancing and managing the following critical success factors.
Leverage and integrate data and processes
- Is MRA included in your Medical Management and Quality Improvement Strategies? AND Pharmacy!
- Do your systems talk to each other: Interoperability and Integration
- Show me your spreadsheet!
Partner with your partners: Quality over Quantity
- Convene with your vendors and coordinate efforts
- Ensure compliance, patient-centered care and reduce provider abrasion
- Use Provider Incentives wisely
Targeted, Meaningful, Valuable, Actionable Provider Engagement and Education
- Deliver results: Good and Bad
- What is your strategy to engage specialists?
- Support Practice Transformation Models through incentives
Evaluate your current infrastructure to support Clinical Documentation
- More than just Coding- Population Health Management
For health plans: Make sure you are prepared for ICD-10, studies show that your providers don’t think you are
- Have you modeled the impact to your Risk Score?
- Are you prepared for DENIALS?
In-Home Assessments: Bring the PCP’s back into the fold
- Target based on complexity and patient care needs, not a money grab
- Care Coordination and medical management is key- align with quality
Shift your chart review and storage strategy
- Retrospective chart reviews…transition to concurrent chart reviews, not a last stich effort
- Do you have a Clinical Documentation Improvement (CDI) strategy?
- Use targeting strategies for patient and provider engagement, not just code collection
Benefit Design and New Member Onboarding
- Pilot new strategies to gather comprehensive patient data from the beginning
- Engage providers for preventive services off the bat
Resources