Why Optimizing Medicare Risk Adjustment for New Enrollees Matters

Payers are not always able to capture accurate or complete data when an individual enrolls in a Medicare or Medicare Advantage plan for health coverage. They often have to rely primarily on self-reported health conditions such as during health risk assessments (HRAs). HRAs are necessary, but they are dependent on members providing accurate and complete information.

There are many barriers to gaining a comprehensive understanding of a patient following enrollment into a health plan. Annual wellness visits can also be flawed since they vary by practice and, often, only a small percentage of beneficiaries participate in them.

An incomplete or inaccurate risk score can have significant implications when Medicare risk adjustment is performed and a risk adjustment factor (RAF) score is applied to the population the payer is covering. Without a medical history to reference and often inaccurate self-reported information, physicians are left to diagnose and treat each individual without the data they need to help qualify their judgments. Having a flawed or incomplete medical record to reference, payers may not be able to determine an accurate RAF score, leading to insufficient reimbursement.

The CMS Rule for Interoperability and Patient Access

In July 2021, the Centers for Medicare and Medicaid Services introduced their rule for interoperability and patient access. It requires CMS-regulated payers and providers to implement and maintain a secure, standards-based patient application programming interface that includes access to longitudinal claims data from payers and clinical information from providers.

Sharing Medicare and Medicare Advantage enrollee data across payers is more likely to result in better patient care and a risk score that is a more fair representation of the risk taken on by the health plan. Considering the number of new members with missing or inaccurate information, the potential impact on clinical outcomes and RAF scoring is huge, as is the opportunity for substantially improving care management programs.

Data: The Solution and the Challenge

Access to longitudinal claims data from patients’ prior payer and clinical information from previous providers is the missing element for most health plans. This critical data can result in improved clinical experiences for members, and vastly better and more accurate financial experiences for payers. A more accurate risk assessment ensures that payers receive adequate payment for managing their covered members.

However, even with all of the promise the new CMS rule brings to payers, several challenges remain around retrieving and incorporating this longitudinal claims data and clinical information. There is incredible potential for payers and their beneficiaries to see vast improvements in outcomes once the full picture of risk is unlocked. In our risk adjustment white paper, we discuss in depth the needs, opportunities and challenges faced by the healthcare marketplace in full. Download now to learn more.