Encounter Data Boost in MA Risk Scores in 2021 – CMS Releases 2021 MA Advance Notice Part 1 – Risk Adjustment

CMS wants to increase the amount of encounter data the agency uses to calculate Medicare Advantage (MA) risk scores from 50% to 75%; final 2021 MA payment rates are expected on or before April 6.

Even as the industry continues to express concern over the reliability of encounter data, The HCC Risk Adjustment Model is now driven by medical codes, which reveal the health of patients, in turn increasing payments from CMS to MA plans to cover high risk patients’ cost of care. In 2016, encounter data made up just 10% of the data used to calculate risk scores.

Last month, a report from the HHS Office of Inspector General was generated after concerns MA organizations (MAOs) may use chart reviews to increase risk adjusted payments inappropriately. The agency examined payments billed by insurers for MA plans and found that the companies obtained billions of dollars in additional payments. A summary of the report stated,

Our findings highlight potential issues about the extent to which chart reviews are leveraged by MAOs [Medicare Advantage organizations] and overseen by CMS. Based on our analysis of MA encounter data, we found that MAOs almost always used chart reviews as a tool to add, rather than to delete, diagnoses—over 99 percent of chart reviews in our review added diagnoses.

The 2021 Advance Notice is published in two parts because of requirements in the 21^st Century Cures Act, which mandated certain changes to Part C risk adjustment and a 60-day comment period for such changes.

CMS proposed calculating risk scores for CY 2021 payment as follows:

• 75% of the risk score calculated with the 2020 CMS-Hierarchical Condition Categories (HCC) model and
• 25% of the risk score calculated with the RAPS-based risk scores on the 2017 CMS-HCC model.

The proposal represents a change from the blend in CY 2020 of 50% calculated with the 2020 CMS-HCC model and 50% calculated with the 2017 CMS-HCC model.

Comments on the proposal should be submitted by March 6, 2020. To submit comments or questions electronically, click here and enter the docket number “CMS-2020-0003” in the “search” field , and follow the instructions for ‘‘submitting a comment.’’

Read more from Fierce Healthcare or get details from Healthcare Finance

Modern Healthcare also has the story

Read a summary of the report from HHS OIG,  “Billions in Estimated Medicare Advantage Payments From Chart Reviews Raise Concerns”

Read the CMS Fact Sheet