By Jay Baker

When CMS released the 2019 Medicare Advantage and Part D Rate Announcement and Call Letter, it sent a signal to MA plan leaders that the time is now to get a better understanding of the implications and impact on plan performance, patient care and compliance. At the same time, they must also reassess ways to enhance their capabilities related to reimbursement, medical cost management and risk adjustment. Since these changes can present daunting challenges, it's important for plans to carefully examine many of the key points of the CMS Call Letter:

• Finalizing the proposal to calculate risk scores by adding 25 percent of the risk score calculated, using diagnoses from encounter data and Fee-for-Service (FFS) diagnoses; 75 percent of the risk score calculated with diagnoses from Risk Adjustment Payment System (RAPS) and FFS diagnoses.
• Finalizing an updated Hierarchical Condition Category (HCC) Risk Adjustment model that incorporates most of the proposed changes to the Part C risk adjustment model, such as adding mental health, substance use disorder, and chronic kidney disease conditions to the risk adjustment model, as well as a variety of additional technical updates.
• +3.4 percent expected overall year-over-year change in revenue from Part C Methodology
• Expects the underlying coding trend to increase risk scores, on average, by 3.1 percent
• Plans to begin implementing the "Payment Condition Count Model" to account for members with multiple conditions in 2020

To adapt to these changes, MA plans should put a process into place that enables them to gather and report encounter data, while quickly troubleshooting submission issues.

Adopting Proven Performance, Patient Care and Compliance Solutions

The first step is to seek specialized expertise because financial and clinical adjustments will affect fiscal and operational processes that impact plan performance, patient care and compliance.

The new HCC clinical model, for example, will expand the suspecting and targeting for community populations to conditions and specialties that have not really been previously targeted, such as behavioral specialists and drug and substance care. Targeting expansion is required to ensure accurate counts, and complexity will increase since all will be phased in concurrent to phasing in the Encounter Data Processing System (EDPS) over the RAPS.

Unfortunately, many MA plans lack the resources to effectively address these changes. The key is to integrate risk-adjustment strategies to meet growing regulatory and market demand for care quality that leads to better patient outcomes.

Next Steps -- Focus on Quality Measures

Clearly, the complexity of the CMS-HCC risk adjustment and other CMS changes will increase the burdens on MA plans. This is precisely where medical groups can contribute expertise in meeting the challenges to accurately deliver quality care, document outcomes and report them accurately -- with responsibilities spanning both the health plans and the providers.

The three common themes in successful quality programs are:

• Alignment of incentives and objectives between patients, providers, payers and the government to ensure awareness and incentives for all to work toward the same outcomes.
• Integrating risk assessment, care management, and quality reporting into a holistic care program. Eliminating silos or departments fosters efficiency, as well as an integrated view of the population and outcomes.
• Deploying a technology infrastructure that supports an integrated program from start to finish and year-round to allow for continuous data exchange and the ability to deliver actionable information to the point of service.

For MA plans to remain sustainable, they must plan and prepare for challenges related to patient engagement and quality measures.

One Effective Approach

One important way to optimize clinical insights is with a Physician Record Review (PRR), a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician.

The point of such a thorough review is to give physicians the ability to see progress notes for primary care, specialists' hospital charts, radiology and laboratory results that are not routinely used in standard analytics and gain demonstrable actionable information.

PRR identifies care opportunities in accordance with evidence-based medicine. The best PRR platforms offer physician staff members who are board-certified in their areas of specialty and have extensive risk-adjustment training to uncover the potential for risk-adjusting conditions left undetected by current programs.

PRRs represent one of the best opportunities to focus on HCCs. Specifically, the PRR platform employs a team of physician reviewers to identify HCCs within each patient chart, annotate risk adjustable conditions (by page number), and integrate these outputs into a broader array of activities.

CMS uses HCCs to reimburse MA plans based upon the health of their members. It pays for the predicted cost expenditures of patients by adjusting those payments based on demographic information, Medicaid status and the severity of illness or patient health status as recorded in medical record documentation.

The goal is to provide a complete picture for the risk-adjustment factor, increasing the accuracy of the patient's risk score and, ideally, creating clean claims and faster reimbursements.

To learn more, check out this Fact Sheet, highlighting key points to help Medicare Advantage (MA) plans understand the implications and prepare for changes in 2019.

Jay Baker is the Senior Vice President, Quality and Risk Adjustment Solutions for Advantmed, LLC, a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs. Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members. For more information on Advantmed's solutions visit www.advantmed.com.