CMS’s surprising proposal in the Feb. 15 “45-day notice” for Medicare Advantage plans’ 2014 payment rates to place strict limits on the use of health risk assessments (HRAs) for risk-adjustment purposes is getting mixed reviews from MA industry participants.
Trade group America’s Health Insurance Plans (AHIP), in a March 1 letter to CMS, for instance, urged the agency to “reconsider” the proposal (MAN 2/28/13, p. 1) so that it “does not inappropriately limit inclusion of diagnoses from the 2014 data year that are valid predictors of health status in the subsequent payment year.” But the CEO of one firm that specializes in assessing MA beneficiaries in their homes suggests that what CMS is asking — primarily for HRA findings to be followed up in a subsequent clinical encounter — is what the MA plans with which it works already are doing.
CMS in the 45-day notice said it “is concerned that these risk assessments could be used as a vehicle for collecting risk adjustment diagnoses without follow-up care or treatment being provided to the beneficiary by the plan.” The HRAs, according to the agency, contribute to “increased risk scores and differences in coding patterns between MA and” fee-for-service (FFS), and thus to higher payments for MA plans.
To analyze what is occurring, CMS proposed that beginning with 2013 dates of service, MA plans will have to flag those diagnoses collected in an MA enrollee HRA. And for 2015, the agency added, “CMS is considering excluding, for risk adjustment payment purposes, the diagnosis data collected from MA enrollee risk assessments that are not confirmed by a subsequent clinical encounter by a provider type” approved for such purposes.
AHIP, in detailed comments to CMS, notes first that HRAs “must be offered” to new MA enrollees and as part of the annual wellness visit available for both MA and Medicare FFS beneficiaries. Regardless of whether they occur in a physician’s office or, as some MA plans arrange, in the beneficiary’s home or another location “convenient for the enrollee,” AHIP asserts, “it is our understanding that the results can currently be included in the patient’s medical record, and diagnoses may be reported for risk adjustment” when the assessments are conducted “face-to-face by medical professionals.”
Adds the trade group: “CMS’ proposal appears to signal a re-evaluation of its policies in the fundamental areas of medical record documentation and the role of chronic conditions in the risk adjustment model. We strongly disagree with the conclusions reflected in the draft Call Letter.” If CMS “has concerns that some health risk assessments are not sufficiently thorough,” AHIP says, it should consider developing criteria for HRAs to address this issue “rather than potentially disallowing all diagnoses collected through these efforts.”
And the group calls the HRAs the foundation of care management programs and counseling for beneficiaries that, while they may “not be documented in a subsequent medical record,” are valued by beneficiaries and “clinically significant.”
Jack McCallum, M.D., CEO of CenseoHealth, a Dallas-based firm that conducts in-home health evaluations for MA and other health plans, tells MAN that “what MA is doing is not upcoding; it’s more accurate coding.” And he says the issue CMS is raising is just a short-term one, since in about 2016 it will have enough provider encounter data from MA plans that it can rely on an “MA-specific model” as a basis for diagnosis-related decisions.
There are several problems with what CMS is proposing in the 45-day notice regarding HRAs, according to McCallum. One is that there now is no specified method for collecting data from HRAs, and there is not even a definition of what constitutes an HRA. It can’t be limited to what is done by primary care physicians, since many Medicare beneficiaries don’t get care from PCPs, he says.
And the “underlying beauty” of the risk-adjustment system, in McCallum’s view, is that it gives MA plans an incentive to figure out where there are gaps in care and to be “productively involved” in finding non-inpatient ways to furnish this treatment since a good HRA will lower costs of care “down the road.”
CenseoHealth, he asserts, never captures a diagnosis on a beneficiary in a home HRA without recommending follow-up care for that beneficiary. Moreover, it has ways, including via its call center and claims tracking, to check whether these recommendations are acted on, McCallum notes. He says that CMS verification of such follow-up would not be a problem for CenseoHealth, and to the extent that there are plans doing HRAs just “for the money,” he would “share the agency’s concern.”
If the CMS proposal were adopted, McCallum tells MAN, it would be “my suspicion” that some entities just collecting diagnoses and not doing anything about what they find “might go away.” The extra scrutiny in this aspect of what CMS is considering is “fine” and “appropriate,” he says, but he adds that “I’m not sure how much of what CMS is worried about is really going on.”
CMS in the 45-day notice said it “is concerned that these risk assessments could be used as a vehicle for collecting risk adjustment diagnoses without follow-up care or treatment being provided to the beneficiary by the plan.” The HRAs, according to the agency, contribute to “increased risk scores and differences in coding patterns between MA and” fee-for-service (FFS), and thus to higher payments for MA plans.
To analyze what is occurring, CMS proposed that beginning with 2013 dates of service, MA plans will have to flag those diagnoses collected in an MA enrollee HRA. And for 2015, the agency added, “CMS is considering excluding, for risk adjustment payment purposes, the diagnosis data collected from MA enrollee risk assessments that are not confirmed by a subsequent clinical encounter by a provider type” approved for such purposes.
AHIP, in detailed comments to CMS, notes first that HRAs “must be offered” to new MA enrollees and as part of the annual wellness visit available for both MA and Medicare FFS beneficiaries. Regardless of whether they occur in a physician’s office or, as some MA plans arrange, in the beneficiary’s home or another location “convenient for the enrollee,” AHIP asserts, “it is our understanding that the results can currently be included in the patient’s medical record, and diagnoses may be reported for risk adjustment” when the assessments are conducted “face-to-face by medical professionals.”
Adds the trade group: “CMS’ proposal appears to signal a re-evaluation of its policies in the fundamental areas of medical record documentation and the role of chronic conditions in the risk adjustment model. We strongly disagree with the conclusions reflected in the draft Call Letter.” If CMS “has concerns that some health risk assessments are not sufficiently thorough,” AHIP says, it should consider developing criteria for HRAs to address this issue “rather than potentially disallowing all diagnoses collected through these efforts.”
And the group calls the HRAs the foundation of care management programs and counseling for beneficiaries that, while they may “not be documented in a subsequent medical record,” are valued by beneficiaries and “clinically significant.”
Jack McCallum, M.D., CEO of CenseoHealth, a Dallas-based firm that conducts in-home health evaluations for MA and other health plans, tells MAN that “what MA is doing is not upcoding; it’s more accurate coding.” And he says the issue CMS is raising is just a short-term one, since in about 2016 it will have enough provider encounter data from MA plans that it can rely on an “MA-specific model” as a basis for diagnosis-related decisions.
There are several problems with what CMS is proposing in the 45-day notice regarding HRAs, according to McCallum. One is that there now is no specified method for collecting data from HRAs, and there is not even a definition of what constitutes an HRA. It can’t be limited to what is done by primary care physicians, since many Medicare beneficiaries don’t get care from PCPs, he says.
And the “underlying beauty” of the risk-adjustment system, in McCallum’s view, is that it gives MA plans an incentive to figure out where there are gaps in care and to be “productively involved” in finding non-inpatient ways to furnish this treatment since a good HRA will lower costs of care “down the road.”
CenseoHealth, he asserts, never captures a diagnosis on a beneficiary in a home HRA without recommending follow-up care for that beneficiary. Moreover, it has ways, including via its call center and claims tracking, to check whether these recommendations are acted on, McCallum notes. He says that CMS verification of such follow-up would not be a problem for CenseoHealth, and to the extent that there are plans doing HRAs just “for the money,” he would “share the agency’s concern.”
If the CMS proposal were adopted, McCallum tells MAN, it would be “my suspicion” that some entities just collecting diagnoses and not doing anything about what they find “might go away.” The extra scrutiny in this aspect of what CMS is considering is “fine” and “appropriate,” he says, but he adds that “I’m not sure how much of what CMS is worried about is really going on.”
Reprinted from MEDICARE ADVANTAGE NEWS,
March 14, 2013Volume 19Issue 5
