CMS proposes using only encounter data for Medicare Advantage risk adjustment and payment

Elvera Bartels

For 2022, the Facilities for Medicare and Medicaid Providers is proposing to  use only come upon details in calculating threat adjustment utilised to pay Medicare Gain strategies.

The Section C threat score would count completely on come upon details as the supply of MA diagnoses, CMS claimed in releasing Section I of the 2022 Medicare Gain Advance Observe.
This signifies a transform from the blend for 2021 of seventy five% of the threat score calculated employing the 2020 CMS-HCC design and 25% of the threat score calculated employing the more mature 2017 CMS-HCC design.

WHY THIS Issues

The transform is demanded by the twenty first Century Cures Act. 

CMS calculates threat scores employing diagnoses submitted by MA organizations and from Medicare rate-for-provider promises. 

Historically, CMS has utilised diagnoses submitted into CMS’ Danger Adjustment Processing Procedure (RAPS) by MA organizations for the goal of calculating threat scores for payment. 

In modern years, CMS commenced accumulating come upon details from MA organizations, which also includes diagnostic info. CMS commenced employing diagnoses from come upon details to compute threat scores for CY 2015, and has considering that continued to use a blend of come upon and RAPS details-primarily based scores.

Also, for CY 2022, CMS is proposing to discontinue the coverage of supplementing diagnoses from come upon details with diagnoses from inpatient information submitted to RAPS for calculating beneficiary threat scores.

THE Larger sized Craze

This announcement of Medicare Gain and Section D payment methodologies is becoming produced approximately 3 months before than common to present Medicare Gain organizations and Section D sponsors a lot more time to acquire this info into thing to consider as they prepare their bids for 2022.

The before release will aid Medicare Gain and Section D strategies to much better address estimating 2022 program charges, in gentle of the uncertainty associated with the COVID-19 pandemic.

The Advance Observe Section I includes info about Medicare Gain threat adjustment for 2022 with a 60-working day comment period of time. Other adjustments to payment methodologies for 2022 that are usually contained in the Advance Observe Section II only involve a thirty-working day comment period of time and will be produced at a afterwards time. 

The Medicare Gain and Section D payment policies for 2022, talked over in the two Section I and Section II of the Advance Observe, will be finalized in the 2022 Level Announcement posted no afterwards than April 5, 2021.

Twitter: @SusanJMorse
E mail the author: [email protected]

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