The Biden administration needs to do more to address the impact of the pandemic on Medicare Advantage enrollee risk scores, a key payer group charges.
The insurance lobbying group AHIP said in comments on the MA and Part D advance notice, which details payment rates and policies for the 2023 coverage year, that plans need more stability on calculating the risk scores that could be affected by the COVID-19 public health emergency. Groups also called for more standardization in how to collect and use social risk factor data to improve health equity.
AHIP was concerned that the Centers for Medicare & Medicaid Services (CMS) doesn’t detail in the advance notice the extent to which patients have delayed or forgone care due to the pandemic and how that has limited providers’ “ability to accurately and completely document enrollee healthcare conditions,” according to the group’s comments.
The PHE gives providers more flexibility to get reimbursement for telehealth from Medicare and exempts providers from key reporting requirements to ease administrative burdens.
But it remains unclear how long the PHE will be in effect and what will happen when it goes away. Department of Health and Human Services Secretary Xavier Becerra extended the PHE into April, and the agency promised to give 60-day notice before it expires. That means the PHE will likely be extended again for another 90 days into this summer.
AHIP called on CMS to allow plans to carry over diagnosis codes for any “non-curable chronic conditions documented in prior years for purposes of determining enrollee risk scores,” the group said in comments.
The group said CMS’ own data have shown a major drop in risk scores for Medicare beneficiaries because of the PHE, due in part to incomplete risk score reporting from providers. Risk scores affect the payments MA plans can receive from Medicare.
“Artificially decoupling actual health from risk scores can undermine the high-quality care and benefits seniors and people with disabilities deserve,” the group’s comments said. “As the PHE continues without any clear end date, we will likely see continued adverse impacts on the use of primary care and the providers who are critical to documenting diagnoses for purposes of determining risk-adjusted payments in 2023.”
CMS should also allow diagnosis codes from audio-only telehealth visits to count toward risk scores for all payment years since the start of the PHE.
The recommendations come as the MA program has been criticized by some lawmakers in Congress for using upcoding to get overpayments from Medicare.
AHIP also supported the agency’s focus on improving health equity via MA and Part D. CMS asked for comments on potential quality measures to include into star ratings for health equity for MA plans.
But AHIP warned that any risk adjustment for social determinants of health should be “fairly and consistently applied.”
AHIP was also worried that standards are still being identified for collecting and sharing social determinants of health (SDOH) data. Collecting such data could be a major administrative burden for providers.
“There are significant barriers to provide collection of SDOH data,” AHIP said. “And even if physicians and other providers could overcome those barriers, asking them to collect and code social risk factors for all patients will add significant burden to providers already overworked by non-clinical tasks.”
The American Medical Group Association (AMGA), which represents medical groups, wrote in comments that CMS needs to create a more standardized SDOH model.
“Health plans currently do not have a central or uniform method to report social risk factor data at scale,” the AMGA said. “Before collecting such information, it is important that CMS evaluate which current data sources exist and how they might be leveraged in a risk adjustment model.”
The final rate notice will be released no later than April 4.