Strategic Planning Items for 2021

Now that 2021 has begun, the stress put on the healthcare industry by the COVID-19 pandemic is becoming increasingly evident. The disturbance in care caused by the pandemic has impacted Medicare Advantage payer risk scores resulting in unfavorable circumstances for risk adjustment. But there have been some positive effects as well, for example, the surge in Medicare telehealth adoption across providers. Here are a few checklist items to help your organization examine your 2021 Medicare risk adjustment strategy.

100% EDS for Risk Score Calculation

CMS announced the shift to 100% EDS for 2022 plan year in their Advance Notice Part 1 for calendar year 2022. This makes 2021 dates of service claim capture extremely important as additional RAPS diagnoses are removed from RAF score calculations. Experts project a 1-3% impact to risk scores as plans adjust to the new approach. Healthcare organizations can prepare by creating reporting models that rely solely on encounter data responses. Investing heavily in prospective risk adjustment programs and capturing diagnoses close to the point of care to ensure diagnosis are reported accurately in claim transactions. Organizations can execute a final RAPS to EDS reconciliation to decide the true medical risk adjustment impact and confirm your submission partner has an abandon plan in place for RAPS.

Medicare Advantage Final Run Extension

Until August 2, 2021 CMS is accepting all 2019 service dates for the 2020 final run, adding six months for risk adjustment data submission. The deadline is still February 1, 2021 for the 2020 interim final run. Plans can benefit from the additional time by creating a chase project for members who were new to plan in 2020. Plans can execute a second pass HCC coding review for targeted populations. Or lastly, identify any missed or dropped records across the data submission network by implementing a data submission recovery project.

Compliance

Lawsuits persist against Medicare Advantage Organizations (MAOs) referencing the False Claims Act which holds plans responsible for the accuracy, completeness and truthfulness of the submitted data. MAOs should continue to assess their Medicare risk adjustment programs and HCC coding for accurate and complete submissions of diagnoses data. To be prepared, consider performing targeted HCC review for conditions at high risk of documentation errors. Assess whether your organization can identify codes that are not supported by proper documentation. Also, consider investing in and deploying a prospective HCC medical coding software program.

Evaluate Vendor Performance and Contracts

Most MAOs rely on vendors to manage their Medicare risk adjustment programs. These organizations specialize in a wide range of service delivery areas such as disease discovery, suspecting analytics, prospective technology enabled solutions, medical record retrieval, and computer assisted coding. The contributions from your partners can be the difference between financial sustainability or insolvency. Ways to evaluate whether your current vendors are meeting your expectations are to make sure the scope of work is updated and executed, determine if payment schedules are competitive, and to explore if your vendor has any new service or technology offerings. Many new technologies in use today utilize artificial intelligence in healthcare such as machine learning and natural language processing (NLP) to discover conditions that often go undocumented.  

Coding and Documentation Updates

Changes in the evaluation and management (E/M) level calculation process for 2021 dates of service has moved away from measuring the complexity of tasks into a more straightforward measurement of E/M. Physicians can now document the code assignment on either the total time related to the visit or the medical decision associated with the visit.

A decrease in the amount of historical data required may have a negative impact on plans ability to document chronic conditions in the note, but not coded in the encounter. Comprehensive problems lists, and past health histories are heavily relied upon during retrospective chart reviews. Some rules may fall from encounter documentation with less focus on these elements in calculation of E/M. Health plans can be prepared by monitoring their electronic health record systems encounter templates to confirm changes do not affect the amount of data documented from a patient encounter. Additionally, plans must ensure members continue to receive annual wellness visits in the course of a calendar year, capturing all chronic conditions like diabetes or COPD.

Do you want to increase the profitability of your Medicare risk contracts for 2021? Perfect your RAF scores and your compliance strategy with A.I. powered HCC risk adjustment coding software from ForeSee Medical.

Blog by: The ForeSee Medical Team