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.
Full Answer
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 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 Medicaid risk adjustment?
Medicaid risk adjustment identifies the demographics of an enrollee and uses different values of risk score calculation for disabled individuals, adults, and children. The Medicaid risk adjustment model is concurrent in that the current year’s diagnoses affect the current year’s risk score.
What is risk adjustment contract?
Remember that the risk adjustment contract is between the program agency (state or federal government) and the health plan. If payments based on diagnoses are not supported in a RADV, the program agency will recoup overpayments from the health plan, not the provider.
What is the purpose of capturing diagnoses in an HCC model?
The purpose of capturing diagnoses in an HCC model is to offer an accurate assessment of the patient’s health status, and correct reporting of diagnosis codes is essential to this process. Not every one of the more than 70,000 diagnosis codes available in the ICD-10-CM code set maps to an HCC to be used in HCC risk score calculation; only conditions that are costly to manage from a medical or prescription drug treatment perspective are likely to be found in the risk adjustment model’s HCC crosswalk.
What is a risk score?
A risk score is the numeric value an enrollee in a risk adjustment program is assigned each calendar year based on demographics and diagnoses (HCCs). The risk score of an enrollee resets every January 1 and is officially calculated by the state or government entity overseeing the risk adjustment program the member is enrolled in. Another term for risk score is risk adjustment factor (RAF), sometimes referred to as RAF score.
What is Medicaid Chronic Illness and Disability Payment System?
Medicaid Chronic Illness and Disability Payment System (CDPS) is the risk adjustment payment methodology states use for Medicaid beneficiaries who enroll in a Managed Care Organization (MCO). While each state has its own set of eligibility criteria, in general, Medicaid (the federal branch of CMS partnering with states) provides health coverage for qualified low-income families and children, pregnant women, the elderly, and people with disabilities. Medicaid beneficiaries may enroll or disenroll at any time. Applying for Medicaid can be done on the Marketplace exchange.
What is the formula used to compare a plan's risk score to the average across all plans?
According to the National Health Council, CMS applies a formula to compare each plan’s average risk score to the average across all plans. Typically, if a plan’s risk score is higher than the average risk score for all plans in their state, the plan gets additional money called a transfer payment.
When was commercial risk adjustment created?
Commercial risk adjustment was created by the Patient Protection and Affordable Care Act (ACA) of 2010 and implemented in 2014. This type of payment model serves individuals and small groups who purchase insurance through the online insurance exchange called the Health Insurance Marketplace.
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…