As its beneficiary population continues to expand, the Medicare program faces persistent pressure to do more with less. With The Centers for Medicare & Medicaid Services (CMS) facing continual legislative and regulatory payment policies, along with significant program cuts, budgets are sure to further tighten across the program, potentially impacting benefits for individuals enrolled in Medicare Advantage (MA) programs.... Read More
In its Summer 2016 newsletter, the Resource Initiative and Society for Education (RISE) features an interview with Verscend experts on the hot topic of the Centers for Medicare & Medicaid Services’ (CMS’) shift in how the risk adjustment factor scores for Medicare Advantage (MA) will be determined going forward. The interview sheds light on the implications of the transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS).... Read More
2016 is expected to present new risk adjustment reporting challenges for Medicare Advantage plans. We recently visited with our internal analytics expert, Suzanna-Grace Sayre, to learn more about how CMS policy changes may affect plans going into the New Year and beyond.
While the U.S. healthcare system is known for its rapid access to specialty providers and patient-centered care, the country continues to struggle with managing healthcare costs, expanding access, and improving efficiency. The United States is consistently ranked the most expensive healthcare system in the world, spending over 17 percent of its GPD on healthcare compared to an average of 10 percent among other developed countries. Healthcare expenditures are continuing their upward trend and the forecast looks bleak as the population ages into Medicare eligibility and premiums and cost-sharing continue to rise. As one method to bend the cost-curve and improve patient health the idea of value-based insurance design (VBID) is gaining traction.... Read More
While the Medicare Advantage risk adjustment model has been in place for several years now, health plans are just beginning to fully understand the model and its impact on payment for certain subsets of the Medicare population, especially those that are dually eligible for Medicare and Medicaid. Dual-eligible beneficiaries have many demographic and health-related characteristics that differentiate them from other populations, as well as influence how they are scored under the risk adjustment model.... Read More
Health plans providing Medicare Part C (Medicare Advantage) coverage to beneficiaries are often under pressure to correctly identify, document, and report their members’ risk score to the Centers for Medicare & Medicaid Services (CMS) in a timely manner. Under its risk-adjusted payment model, CMS agrees to match member funding to the actual health profile of the member, which helps to ensure appropriate levels of care, but the challenge is that the burden of determining and proving that health risk profile falls on the health plan..
It seems that just as Medicare Advantage plans understand a standard set of reporting rules, CMS makes large changes to the risk-adjusted payment model and its reporting methodology. The latest wave of rule changes significantly impacted the way that Medicare Advantage plans score risk, report conditions, and calculate bid rates in risk adjustment. The bullets below outline key changes in risk adjustment in 2015:... Read More
Integrated care delivery is an emerging trend in healthcare. Under this model, healthcare organizations and providers work together to coordinate care for a defined population. As the industry transitions from volume to value-based compensation, it is likely that integrated care delivery will gain popularity. In fact, the number of lives covered under value-based risk contracts is predicted to grow by 30 percent through 2020. Instead of being loosely tied through networks and payment models, integrated care delivery strengthens the relationship between health plans and providers, helping to rid organizations of disparate, wasteful, and costly care