Payer, provider groups clamor for CMS to add audio-only telehealth visits to MA risk adjustment

A collection of payer and provider groups is demanding the Biden administration allow Medicare Advantage plans to include audio-only telehealth visits in risk adjustment calculations. 

The demand was outlined in a letter to Department of Health and Human Services and Centers for Medicare & Medicaid Services (CMS) leadership released Thursday. The groups were concerned that the inability to incorporate telehealth audio-only visits has impacted payments to plans and negatively hurt vulnerable populations that don't have access to video capabilities.

Medicare Advantage’s risk adjustment program assigns a risk score to each beneficiary that reflects their overall health costs based on factors such as age and underlying disease. The risk score reflects how much an MA plan gets paid for covering services and offering benefits.

For 2020 and 2021, CMS let MA plans include video-based telehealth encounters when submitting diagnosis information for risk adjustment calculations. However, MA plans cannot do this for audio-only telehealth encounters, meaning they may not be submitting the full information to CMS, and that could impact payments and benefits, the groups said.

“Without the complete and accurate documentation of diagnoses, MA plans are experiencing reductions in payments, leaving health plans and providers with fewer resources and potentially exposing patients to reduced benefits, higher premiums and increased out-of-pocket costs in the future,” the letter said.

Telehealth use blossomed during the pandemic after CMS gave more flexibility for providers to get reimbursed by Medicare for such services. But not including audio-only encounters could disadvantage vulnerable populations such as low-income or medically fragile beneficiaries that do not have video capabilities, the letter said.

“Seniors with underlying conditions are trying to stay and get care anywhere because of the practicality of it,” said Michael Bagel, director of policy for Alliance of Community Health Plans (ACHP), which represents community-based and provider-aligned health plans. 

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ACHP led the letter that was also signed by groups that include America’s Health Insurance Plans, America’s Physician Groups, the Blue Cross Blue Shield Association, the Better Medicare Alliance and the Healthcare Leadership Council.

Groups were especially incensed that CMS allowed Affordable Care Act plans to count both video and audio telehealth in their encounters for risk adjustment.

“It is fundamentally unfair to seniors to apply different standards from one federal program to another, unreasonably limiting the ability to fully properly document risk to select programs,” the letter said.

The groups are pressing CMS to create a 24-month look-back period that would supplement 2020 data used to calculate 2021 risk scores.

“Allowing health plans to supplement 2020 encounter data with data from 2019 would mitigate the negative impact of under-risk-adjusting as a result of care delivered through unallowable encounters during the pandemic,” the letter said.

The groups’ concerns come as the healthcare industry is trying to figure out what telehealth will look like after the pandemic is over.

Currently, the flexibilities for telehealth will remain in place through the duration of the COVID-19 public health emergency, which is expected to run through the rest of this year. CMS has said that it will need congressional intervention to make some of the flexibilities permanent.

Congress is exploring legislation to make some parts of the telehealth expansion in Medicare and Medicaid permanent.