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- INOC | NOC for Data Center on Network Adequacy Test Submissions for Medicare-Medicaid Plans
- Raji on Obamacare Reinsurance and Risk Adjustment, Year One.
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Tag Archives: risk adjustment
The fall season is a good reality check – back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future – you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future performance and challenges.
The signing of the Affordable Care Act (ACA) into law threw health insurers into a whirlwind of changes. The guaranteed issue law made it so no enrollee in the individual or small group commercial market would be denied coverage due to their health status. In addition, the rate for all members now had to stay the same for all enrollees, with fluctuations only allowed for a few factors such as tobacco status. That key process, known as underwriting, could no longer serve as the method to evaluate risk and either deny coverage or set the enrollee’s premium accordingly. With that shift came the introduction of risk adjustment, reinsurance, and risk corridor (“3 Rs”) into the commercial market.
Unfortunately, Risk Adjustment does not have the luxury of taking the summer off. As CMS continues to stress the criticality of submitting complete, timely and accurate data to support plan payments related to Risk Adjustment, health plans must have year-round processes in place to ensure compliance as well as accurate payment from the government.
By now you may have received your score from the Centers for Medicare & Medicaid Services (CMS) regarding the national sample for Risk Adjustment Data Validation (RADV) audits.
Do you know your level of exposure for overpayment recovery from CMS?
On March 3, 2015, Cheri Rice, CMS’ Director of Medicare Plan Payment Group, released a memo notifying all Medicare Advantage Organizations, PACE Organizations, and certain Demonstrations of its intent to rerun risk scores during the calendar year 2015. If you read this memo and muttered, “uh oh” under your breath, you might be thinking that your plan/organization owes CMS some money, and soon. If you haven’t read this memo, “uh oh” would be an understatement.
Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company’s risk adjustment coding and data collection practices. The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act. The company has over 3.2 million Medicare Advantage members.
Seriously, the first question is, “what do you have under the hood for risk adjustment in your health plan?” If you’re running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don’t have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it’s not just plans on the Exchanges, it’s all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!