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

For 2022, the Facilities for Medicare and Medicaid Expert services is proposing to  use only come upon information in calculating threat adjustment employed to fork out Medicare Benefit strategies.

The Portion C threat score would count entirely on come upon information as the supply of MA diagnoses, CMS reported in releasing Portion I of the 2022 Medicare Benefit Progress Notice.
This represents a modify from the mix for 2021 of seventy five% of the threat score calculated applying the 2020 CMS-HCC model and twenty five% of the threat score calculated applying the older 2017 CMS-HCC model.

WHY THIS Matters

The modify is necessary by the twenty first Century Cures Act. 

CMS calculates threat scores applying diagnoses submitted by MA organizations and from Medicare cost-for-service promises. 

Historically, CMS has employed diagnoses submitted into CMS’ Threat Adjustment Processing Program (RAPS) by MA organizations for the function of calculating threat scores for payment. 

In modern many years, CMS started collecting come upon information from MA organizations, which also consists of diagnostic facts. CMS started applying diagnoses from come upon information to work out threat scores for CY 2015, and has given that ongoing to use a mix of come upon and RAPS information-centered scores.

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

THE Larger sized Development

This announcement of Medicare Benefit and Portion D payment methodologies is currently being produced roughly a few months previously than standard to offer Medicare Benefit organizations and Portion D sponsors far more time to take this facts into thing to consider as they get ready their bids for 2022.

The previously launch will assist Medicare Benefit and Portion D strategies to improved tackle estimating 2022 system prices, in light of the uncertainty connected with the COVID-19 pandemic.

The Progress Notice Portion I consists of facts about Medicare Benefit threat adjustment for 2022 with a sixty-day remark period. Other changes to payment methodologies for 2022 that are ordinarily contained in the Progress Notice Portion II only demand a thirty-day remark period and will be launched at a later time. 

The Medicare Benefit and Portion D payment policies for 2022, talked about in equally Portion I and Portion II of the Progress Notice, will be finalized in the 2022 Charge Announcement published no later than April five, 2021.

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