Risk Adjusted Reimbursement (MRA) Chart Reviews. Chart reviews are in-depth audits that assess the provider’s understanding and compliance with proper documentation and coding, thus validating submitted information to ensure proper payment. Reviews are accomplished after extensive data analysis, and encompass as much historical information as necessary to assure a complete understanding of the patient’s health status.
What is MRA Medicare risk adjustment?
What is MRA? MRA – Medicare Risk Adjustment – was established in 2003 and phased in over a five year period. Risk adjusted reimbursement attempts to fund providers for the anticipated costs of care based on the patient's health status.
What is going on with risk adjustment payments?
- “Ensure the accuracy and integrity of risk adjustment data submitted to CMS. ...
- Implement procedures to ensure that diagnoses are from acceptable data source. ...
- Submit the required data elements from acceptable data sources according to the coding guidelines.
What are risk adjustment factors?
Risk Adjustment Factors — known as RAFs — are the average risk scores for specific HCCs. They’re used in combination with demographics to determine an individual’s final risk score. The higher a person’s RAF, the more likely it is that they’ll end up in high-risk adjustment programs or see increased premiums due to their diagnosis ...
What is retrospective risk adjustment?
retrospective risk adjustment process. Millions of Medicare Advantage medical charts are retrieved and coded manually . each year to generate a more complete picture of member health status. Traditional retrospective risk adjustment processes lacked the technology and tools to precisely identify medical charts that support unreported diagnosis codes.
What is risk adjustment review?
Risk Adjustment (RA) is a payment methodology used by the Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS) to adjust payments to Medicare Advantage and Marketplace plans, such as those offered by Quartz.
What is a Medicare risk adjustment?
Risk adjustment is used to adjust payments to Medicare Advantage Organizations (MAOs), Program of All Inclusive Care for the Elderly (PACE), certain demonstrations and Part D sponsors for the expected healthcare costs of their enrollees based on disease factors and demographic characteristics.
What is the purpose of risk adjustment?
The primary goal of risk adjustment is to provide appropriate funding to health plans to cover the expenses of their enrollees and to discourage incentives for health plans to selectively enroll healthier members. It is intended to provide an environment where health plans compete on quality and efficiency.
How does risk adjustment work in healthcare?
As defined by the Centers for Medicare and Medicaid Services (CMS), risk adjustment predicts the future health care expenditures of individuals based on diagnoses and demographics. Risk adjustment modifies payments to all insurers based on an expectation of what the patient's care will cost.
How does risk adjustment benefit patients?
In its simplest terms, risk adjustment ensures that the health conditions, health status, and demographics of the beneficiaries in a Medicare Advantage or an Affordable Care Act plan are accurately documented—and that the health plans managing those beneficiaries are adequately compensated for that management.
How is Medicare risk adjustment score calculated?
The purpose of the Medicare risk scores is to estimate a relative cost factor. (i.e., it is a payment risk score). CMS calculates individual beneficiary-level risk scores by adding the relative factors associated with each beneficiary's demographic and disease factors. The CMS Payment Risk Score is built up each year.
What are the goals of Medicare risk adjustment?
The goal of risk adjustment is to enable more accurate comparisons across TINs that treat beneficiaries of varying clinical complexity, by removing differences in health and other risk factors that impact measured outcomes but are not under the TIN's control.
What is Medicare health risk assessment?
The HRA process is intended to identify members who may have high-risk health care needs and provide baseline health status for care management programs. The process allows Security Health Plan to refer members into three areas of care: Case management. Disease management. Wellness management.
What is Medicare risk Adjustment HCC coding?
HCC coding relies on ICD-10-CM coding to assign risk scores to patients. Each HCC is mapped to an ICD-10-CM code. Along with demographic factors such as age and gender, insurance companies use HCC coding to assign patients a risk adjustment factor (RAF) score.
What is a RAF score?
A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient's health status. RAF scores are used to predict the cost for a healthcare organization to care for a patient.
What does HCC mean after a medical diagnosis?
Hierarchical Condition CategoriesHCCs, or Hierarchical Condition Categories, are sets of medical codes that are linked to specific clinical diagnoses. Since 2004, HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions.
How are RAF scores calculated?
The amount the government pays is calculated by a formula—multiplying the government's “county rate” by the patient's risk adjustment factor or RAF score. County rate x RAF score = Monthly capitation rate.
What is Medicare Part C?
It includes both hospital insurance (Part A) and medical insurance (Part B). Medicare Part C, aka Medicare Advantage, is an alternative to Original Medicare.
Does Medicare pay per capita?
The federal government pays Medicare Advantage plans a "per capita" rate for each Medicare beneficiary. This rate is based on a risk assessment score. In order to boost those scores and to maximize the dollars they get from the federal government, insurers may offer you a free home visit with one of their medical providers.
WHY WE DID THIS STUDY
CMS risk-adjusts payments by using beneficiaries' diagnoses to pay higher capitated payments to companies with contracts under Medicare Advantage (MA companies) for beneficiaries expected to have higher-than-average medical costs. This may create financial incentives for MA companies to make beneficiaries appear as sick as possible.
HOW WE DID THIS STUDY
Using previously collected MA encounter data from 2016, we determined whether any MA companies' use of chart reviews and HRAs increased their risk adjusted payments disproportionately relative to their size and their peers.
WHAT WE FOUND
Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs to maximize risk adjusted payments.
WHAT WE RECOMMEND
CMS should (1) provide oversight of the 20 MA companies that had a disproportionate share of the risk-adjusted payments from chart reviews and HRAs; (2) take additional actions to determine the appropriateness of payments and care for the 1 MA company that substantially drove risk adjusted payments from chart reviews and HRAs; and (3) perform periodic monitoring to identify MA companies that had a disproportionate share of risk adjusted payments from chart reviews and HRAs.
Why do Medicare Advantage Organizations invest in retrospective risk adjustment chart reviews?
Why do Medicare Advantage Organizations invest in retrospective risk adjustment chart reviews? RAF scores determine how MAOs get paid— so ensuring accuracy is crucial. Retrospective chart reviews can help MAOs improve the accuracy of risk-adjustment payments by allowing them to add and delete diagnoses in the encounter data based on a patient’s medical records in the EMR. This helps ensure that MAOs that enroll sicker beneficiaries are appropriately compensated for their more costly levels of care.
Does Medicare Advantage have risk adjustment coding?
As Medicare Advantage Organizations have known for years, providers often have robust documentation but lack in risk adjustment coding. There’s a significant opportunity for medical groups to create a stronger HCC coding review process to avoid having to rely on the retrospective review process used by MAOs.
What is risk adjustment?
In risk adjustment, information from health provider records is used by the plan to determine the severity of illnesses of plan members. After these assessments, health plans that have a greater number of “healthier” members are required to transfer funds to plans that have a greater number of “sicker” members.
How to respond to a risk adjustment letter?
But here are some tips when considering your response: 1) Confirm it is a Risk Adjustment Audit. Carefully search the letter you received for the words “risk adjustment.”. Otherwise, the rest of the advice I give here may not apply. 2) Don’t panic about the deadline on the letter.
Important Details on Risk Adjustment in Medicare Advantage
Key Takeaways from The OIG Report
- Below are some of the major findings in the OIG evaluation of chartreviews in MA: 1. 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. 1.1. In CMS’ response letter to the OIG study, CMS did state that, “chart review records are intended for the submission of additional diagnosis codes f…
Implications For Medicare Advantage Organizations
- As a result of these findings, OIG made three recommendations to CMSwith which CMS agreed. Below are the recommendations along with implicationsfor 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. Implications:MAOs that submitted chart revi…