Friendly Changes for Some or All?

Centauri Health Solutions’ Director of Product Strategy – Dawn Carter

On December 27, 2017, CMS released Part 1 of the Advance Notice for Methodological Changes for Calendar Year 2019 for the MA HCC Risk Adjustment Model. The Advance Notice is split into two parts this year as required in the 21st Century Cures Act. We’re pleased to provide our insights on key elements of the Notice.

Until now, only one Advance Notice had been issued per year by the beginning of February, with a Final Notice issued at the end of April. The Cures Act now requires that CMS provide at least 60 days for public review and comment of proposed changes to the risk model and 30 days to comment on risk adjustment changes.

Here’s how we see it:

 

Mental Health, Substance Use and Kidney Disease

To comply with the Cures Act, CMS proposes an MA risk adjustment model that includes additional mental health, substance use disorder and chronic kidney disease conditions.

As an example, CMS proposes to add psychosis and a variety of personality disorders to the payment model. It characterizes psychosis as a mix of acute and chronic conditions that cover a range of psychotic episodes but do not meet the full criteria for a schizophrenia diagnosis, which is already included.

CMS also wants to adjust the payment model so it better accounts for costs related to an accidental drug or alcohol overdose, proposing to add payment model codes for overdoses resulting from misuse of several different drugs, including opioids.

For the more severe diagnosis of chronic kidney disease, already accounted for in the current model, CMS proposes increases to patient risk scores for moderate Stage 3 chronic kidney disease.

 

All Condition Count versus Payment Condition Count

CMS proposes a “Payment Condition Count model” for risk adjustment, which considers the number of conditions that a beneficiary has, but only among the conditions that are included in the payment model. This model is projected to increase MA risk scores for health plans by 1.1 percent.

In contrast, the alternative “All Condition Count” model, which considers all conditions that a beneficiary has, is projected to decrease MA risk scores by 0.28 percent .

If implemented, the changes to the risk-adjustment model would be phased in over three years. In 2019, CMS said payment would be determined based on 75 percent of the old risk adjustment model used for payment in 2017 and 2018, and 25 percent of the proposed new risk adjustment model. By 2022, the new payment model would be phased in fully.

 

EDPS versus RAPS

On the table for 2019 is a proposed blend of 25 percent encounter data processing system-based risk scores (EDPS) with 75 percent risk adjustment processing system (RAPS)-based risk scores.

Although that is an increase from the respective 15 percent to 85 percent of blending EDPS and RAPS in 2018, it is still a slower cutover than was originally planned and announced in prior years. This materially affects risk adjustment operations and financials, particularly the reconciliation of EDPS and RAPS submissions.

If after reading this summary you find yourself wondering how friendly these changes will be for your own risk adjustment operations, there is one thing that guarantees that these changes will be unfriendly: poor data quality.

CMS has published an increasing number of metrics for monitoring the completeness, timeliness and accuracy of submitted data. Any data that rejects and contains diagnoses that map to an HCC will affect risk scores. Therefore, it can be clearly concluded that data quality for your EDPS/RAPS submissions will matter more than ever.

Some industry experts believe that the proposed methodological change to risk adjustment is “more industry-friendly than the status quo.” Others feel that it favors larger market share entities. However, I’m hopeful that it is a good sign for the sector as a whole.

Do you have tools that can clearly tell you how complete and accurate your data is at any given point in time?

Can your tools clearly show you how much revenue you stand to lose if you do not address data quality issues?

If you answered no to either question, call us at Centauri Health Solutions today and speak to an expert. Allow us to engage with you as a trusted partner to help you solve the unique problems of compliance and payment accuracy in risk adjustment that are unique to your organization.

 

 

About Centauri Health Solutions

Centauri Health Solutions focuses on revealing care opportunities through its suite of products and services. Delivering data-driven services, through private cloud-based software solutions, the firm provides comprehensive data management designed specifically for risk adjustment and quality-based revenue programs, in addition to enrollment and eligibility solutions. Centauri improves member outcomes and financial performance for health plans, hospitals and at-risk providers by supporting initiatives in health care enrollment, risk adjustment, RADV risk mitigation, HEDIS and Star Ratings. Headquartered in Scottsdale, Ariz., Centauri Health Solutions also has offices in Cleveland, Ohio, Nashville, Tenn., and Orlando, Fla. For more information, visit www.centaurihs.com.