This has been a difficult series of articles for our company, summarizing the 2024 changes to the CMS-HCC risk adjustment model. And we imagine our clients are speechless when considering the financial ramifications to their businesses. If you’ve missed any of the installments, click here for Part 1, which links you to each subsequent article. However, remember that the changes will be phased in over time. This means that for the rest of 2023, you will be paid at 100% for the conditions currently in the model and slightly less next year. MRA payments lag the reporting year so the payment impact will be delayed 12 to 18 months.
We strongly suggest:
- Embarking on a most comprehensive campaign of retrospective chart reviews to uncover any “hidden” conditions in your members’ charts. These are diagnoses currently in the model which you may not have been reporting and/or about which you may have been uninformed. Consider engaging a third-party organization to assist with retrospective reviews and to evaluate your medical coding and documentation and confirm its robustness to withstand regulatory scrutiny.
- Ensure that you have solid evidence – filed in the chart and documented on the progress note – for every single risk adjusted condition you’ve reported AND that your provider’s documented assessment meets M-E-A-T criteria. Remember, risk adjustment is not about getting paid because patients have certain conditions but because you have demonstrated how those conditions are doing and how you’re managing them.
- Assure you have an airtight system for making sure all of your Medicare Advantage members are being seen in your office at least once in each six-month period and that all risk adjusted conditions are being properly assessed and reported. While telehealth is still allowed by CMS, conduct audio/video visits if patients won’t or can’t come to the office, and perhaps consider a program of house (or ALF) calls by your non-physician practitioners so no one falls through the cracks. Housecall companies external to your practice can be a great tool for the arsenal although the comprehensiveness and quality of those assessments and documentation may vary considerably.
- The Office of Inspector General (OIG) is actively auditing health plans and citing them for provider coding and documentation irregularities. Similarly, many plans are conducting provider audits and finding misdiagnosed or unsupported conditions. Not only does this open your practice up to funding recoupments, but also to penalties and damages for false claims by the OIG. So, step up your practice compliance activities to make sure you’re reporting only legitimate, properly assessed conditions for which there is evidence in the chart.
While the sky may indeed be falling when considering the magnitude of the impending MRA changes, there is a great deal you can do today to position your practice to successful navigate these waters into the next iteration of risk adjustment.