The Center for Medicare and Medicaid Innovation (CMMI) wants to replace or improve its risk adjustment methodology after concerns of Medicare Advantage plans upcoding to get higher payments, the center’s director said.
CMMI Director Liz Fowler, Ph.D., detailed how the center plans to shift the focus in its payment models to care delivery during a webinar Wednesday sponsored by the advocacy group United States of Care. The remarks come as scrutiny over MA coding practices has loomed over the lucrative market.
“There has been a lot written about the ability to engage in coding and upcoding gains and it’s a way of maybe getting better payments or higher payments without actually delivering care,” Fowler said. “We are very well attuned to some of the trends we are seeing.”
Critics have charged that MA plans can draw overpayments from Medicare by submitting unnecessary diagnosis codes and inflating risk scores that can lead to more subsidies and quality bonuses for the payers.
Fowler said the center is looking to address risk adjustment in its ongoing models.
“It’s really crucial to ensure that innovation is around care delivery and not just better ways of gaming the health system and upcoding,” she said.
Fowler mentioned that in one of the models, CMMI has an overall constraint on risk score growth applied across the entire program. It is also applied individually to specific model participants.
“Some of these lessons if they are successful could be applied to [Medicare Shared Savings Program] or MA plans,” she added.
The focus on tackling upcoding is “especially important” as CMMI attempts to put a greater emphasis on health equity in its models going forward, Fowler said.
The center released a strategic refresh last year that focused on improving health equity and streamlining models to reduce duplication and ease burdens for providers to participate. A key goal of the center is to have every beneficiary in fee-for-service Medicare in an accountable care relationship with their provider.
A key part of this push is to entice more provider participation in areas with underserved healthcare needs, particularly in rural areas, Fowler said. She mentioned the Community Health Access and Rural Transformation model, launched last year, which pays providers based on value-based outcomes rather than volume and gives providers upfront investments.
“We are seeing how that goes and looking for other opportunities to engage with rural providers in our health equity efforts,” she said.
Under this new strategic refresh, the center will launch and pull back on some models. Fowler noted it pulled some models such as a Part D modernization model that only had 1% of plans participating, so it did not have enough to evaluate the findings.
“We were looking across the portfolio where the models look to bring success and then going forward, we are using a very specific criteria to select new models,” Fowler said.