Which provider type is not acceptable for risk adjustment coding?
Risk adjustment data are not acceptable when received from facilities with numbers outside the ranges. NOTE: Skilled nursing facilities, home health care, and hospital inpatient swing bed components are not covered entities for risk adjustment data.
What is risk adjustment in Medicare?
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.
Which part of Medicare is affected by CMS HCC?
The CMS- HCC model adjusts Part C monthly payments to Medicare Advantage plans and PACE organizations. Risk scores are relative and reflect the standard benefit: Each beneficiary's risk score is calculated to estimate that specific beneficiary's expected costs, relative to the average beneficiary.
What type of payment system is risk adjustment?
Risk adjustment modifies payments to all insurers based on an expectation of what the patient's care will cost. For example, a patient with type 2 diabetes and high blood pressure merits a higher set payment than a healthy patient, for example. Watch Risk adjustment: An overview for providers.
Which risk adjustment model is most commonly used by Medicaid?
Medicare Risk Adjustment. Medicare risk adjustment is the most widely used risk adjustment model and is connected to Medicare Advantage Organizations.
What is Medicare risk Adjustment HCC coding?
Hierarchical condition category (HCC) coding is a risk-adjustment model originally designed to estimate future health care costs for patients.
What type of insurance is Medicare Part D?
The Medicare Part D program provides an outpatient prescription drug benefit to older adults and people with long-term disabilities in Medicare who enroll in private plans, including stand-alone prescription drug plans (PDPs) to supplement traditional Medicare and Medicare Advantage prescription drug plans (MA-PDs) ...
What are the CMS HCC categories?
The top HCC categories include major depressive and bipolar disorders, asthma and pulmonary disease, diabetes, specified heart arrhythmias, congestive heart failure, breast and prostate cancer, and rheumatoid arthritis.
How many HCC categories are there?
In this Timely Topic, we provide an introduction to the HCC system. Of the approximately 70,000 ICD-10-CM codes, about 9,500 map to 79 HCC categories. The diagnoses must be documented by the physicians who provide care. A Risk Adjustment Factor is assigned to each HCC category.
Which insurance group uses HCC coding?
CMS uses HCCs to reimburse Medicare Advantage plans based on the health of their members. It pays accurately for the predicted cost expenditures of patients by adjusting those payments based on demographic information and patient health status.
What are risk adjustment services?
Risk adjustment is an annual process that is used to appropriately compensate health plans for the costs associated with taking on members with chronic health conditions.
How does risk adjustment affect payments to managed care plans?
Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs.
What is RAS/raps CMS?
CMS internal staff uses RAS/ RAPS to utilize beneficiary data in developing the health riskfactors to be used for payment, to analyze the performance of plans and to address the concernsof MAOs.
When is a periodic review of PII data performed?
Periodic review of PII data is performed during the annual RAS/RAPS Security Control Assessmentas well as during the annual Privacy Impact Assessment review. Reviews are also performed whendata within RAS/RAPS falls outside the scope of the 10 year data retention schedule.
Is MAPD voluntary?
Participation in MA and MAPD plans is voluntary and requires an affirmative election to join. Whenan individual enrolls in a plan, as part of the application package, the beneficiary is required to signthe Agreement Page. Thus, Medicare Modernization Act (MMA) enrollment equates to beneficiaryconsent. The Privacy Act permits CMS to disclose information without an individual’s consent if theinformation is used for a purpose that is compatible with the purpose(s) for which the informationwas collected. Any such disclosure of data is known as a “routine use.” CMS policy prohibits therelease even of non-identifiable information, except pursuant to “routine use.”
Background
Risk adjustment is a statistical method that seeks to predict a person’s likely use and costs of health care services. It’s used in Medicare Advantage to adjust the capitated payments the federal government makes to cover expected medical costs of enrollees.
A Blunt Instrument
While risk-adjustment methodologies may seem arcane, there are big stakes — not just in terms of costs to the federal government, but who benefits and loses. Some research has found that the additional payments driven by risk coding mainly accrue to health plans themselves, in the form of higher profits.
Does Risk Adjustment Worsen Inequities?
Because the current risk-adjustment model relies heavily on past medical spending to determine future payments, a few experts said it could worsen inequities in the system — for example, by underestimating the costs of caring for populations that use fewer services not because they don’t need them, but because they have poor access to medical care.
Better Data Might Help
One way risk adjustment can be improved is by modifying the data on which the model is built.
Moving Forward
All agreed that risk adjustment is worth getting right to ensure plans are paid appropriately based on how well they keep members healthy, not how well they code. Giving plans incentives to find innovative ways to help patients, including those with more complex needs, is key to whether the program fulfills its promise.
What is risk adjustment?
Risk adjustment is an essential mechanism used in health insurance programs to account for the overall health and expected medical costs of each individual enrolled in a health plan. Accurate documentation of diagnoses by clinicians is a critical component of the risk adjustment process.
What is the coding intensity adjustment for Medicare Advantage?
Since 2010, Congress has required CMS to apply a coding intensity adjustment to Medicare Advantage payments that is an across the board cut to Medicare Advantage risk scores. The purpose of the adjustment is to account for differences in coding patterns between Medicare Advantage and FFS Medicare — differences that are a function of the differences between the structural payment and care models in the Medicare Advantage and FFS Medicare programs. Per statute, the coding intensity adjustment has increased from a 3.41% reduction in 2010 to a 5.91% reduction for payment year 2018. The coding intensity adjustment must remain no less than a 5.91% reduction to risk scores for all subsequent years. CMS has the authority to determine the amount above the statutory minimum. To date, CMS has applied the minimum coding intensity adjustment required by law.
What is the difference between FFS and Medicare Advantage?
Accurately identifying illness is key to the comprehensive approach to care in Medicare Advantage. FFS Medicare reimburses providers separately for each episode of care. In contrast, Medicare Advantage is structured to encourage early identification of illness, coordinated care, and improved beneficiary health outcomes.
What is Medicare Advantage?
These plans are approved and regulated by the Centers for Medicare & Medicaid Services (CMS) and the program undergoes an annual review process that makes policy changes and sets payment rates for the next year .
What is the risk adjustment process for Part D?
The basic structure of the risk adjustment process for Part D is the same as for MA. The same diagnoses are used, but the category groupings and the costs are necessarily different. Instead of using FFS costs, only prescription drug costs are taken into account. In addition, instead of using the entire cost, the risk adjustment includes only those costs for which a Part D plan is liable (that is, copayment and deductibles are excluded). This makes it a “plan liability” risk model, rather than a “drug costs” model as such.
When was Medicare implemented?
When Medicare was implemented in 1966 it included two main components, “Part A” for hospital costs (funded by a payroll tax), and “Part B” for physician services (initially voluntary, with a subsidized premium). Both were set up using a FFS system, with hospitals (“Part A”) and physicians and other professional providers (“Part B”) being paid specified fees for each service performed for a Medicare beneficiary. Beneficiaries paid a portion of those fees through deductibles and copayments, as well as a subsidized premium for Part B.
Is MA risk model based on FFS?
As noted above, the MA risk model is based on diagnoses and expenditures for FFS patients. MA payments, on the other hand, are adjusted based on that risk model applied to the diagnoses of MA enrollees. It would be neither practical nor desirable to base the risk model on expenditures of MA plans to care for MA enrollees.