Risk scores will be calculated using 75% encounter data, an
increase of 25% over this year.
The Centers for Medicare and Medicaid Services is continuing to
phase in a greater percentage of encounter data in determining payments to
Medicare Advantage plans.
CMS released Part I of the 2021 Advance Notice this week.
Requirements in the 21st Century Cures Act mandate certain changes to risk
adjustment and a 60-day comment period.
CMS is expected to finalize all changes to MA payments for 2020
in an annual rate announcement that will be released by April 1.
WHY THIS MATTERS
CMS uses the HCC (Hierarchical Condition Category) Risk
Adjustment Model to determine risk scores. They are based, in part, on a
patient's health, which is determined by the medical code. The sicker the
patient, the higher the risk score and greater the payment to MA plans.
Encounter data uses patient information based on clinician
visits. The industry has been against the use of encounter data, saying it is
inaccurate and unreliable.
For CY 2021, CMS proposes to calculate risk scores for MA
payment using 75% of the encounter data-based risk score with 25% of the
risk-adjustment processing system, or RAPS-based risk score.
For 2020, CMS based 50% of the risk score on
encounter data and 50% on RAPS. In 2019, this was 25% and 75%, respectively.
The agency said it would calculate encounter data-based risk
scores based on the 2020 CMS-HCC model and the RAPS-based risk scores on the
2017 CMS-HCC model.
THE LARGER TREND
The 21st Century Cures Act requires CMS to phase in the proposed
changes by 2022.
Historically, CMS used diagnoses submitted by Medicare Advantage
organizations.
In recent years, CMS began collecting encounter data from the
organizations.
Starting in 2016, CMS began using diagnoses from encounter data
to calculate risk scores, by blending 10% of the encounter data-based risk
scores with 90% of the risk-adjustment processing system, or RAPS-based risk
scores.
In 2017, CMS continued to use a blend to calculate risk scores,
by using 25% encounter data and 75% RAPS. In 2018, it scaled back to using 15%
encounter data and 85% RAPS.
Twitter: @SusanJMorse Email
the writer: susan.morse@himssmedia.com
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