Medicare Risk Adjustment Operations

 

APPROVED by the AAPC for 5 CEUs

Course Overview

Medicare Advantage (MA) is one of the fastest-growing and most complex health plan lines of business representing significant growth opportunities for payers. Launching and/or managing a successful MA market requires careful, strategic planning to meet requirements, ensure compliance, and maximize the program benefits for your organization.

Success in this market will depend on success in each of the following essential areas:

• Value-based contracting
• Clinical documentation and coding
• Delivering high quality care
• Managing utilization

This course will touch on all four essential areas of MRA Operations.

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Review the Agenda below:

Risk Adjustment Operations

• Medicare Risk Adjustment Overview
• History of Medicare Risk Adjustment
• Key Concepts and Terms
• Risk Adjustment Data
• Risk Adjustment Process
• Risk Adjustment Data Validation

CMS-HCC Risk Models

• PY 2020 CMS HCC Risk Adjustment Model
• PY 2021 CMS HCC Risk Adjustment Model
• PY 2022 CMS HCC Risk Adjustment Model

Calculating Risk Scores and Payments

• General Payment Rules
• Data Submissions and Payments
• PY 2020 Risk Score Calculations
• PY 2020 CMS-HCC Payment Calculation Example
• PY 2021 Risk Score Calculations
• PY 2021 CMS-HCC Payment Calculation Example

Optimizing RA Operations

• Network Adequacy Guidance
• Medicare Star Ratings
• Growth and Retention
• Reports and Resources

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