CMS proposes full phase-in of encounter data use for Medicare Advantage payments

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, CMS proposes full phase-in of encounter data use for Medicare Advantage payments

CMS on Monday pitched modifications to Medicare Benefit funds for 2022 that may full a multiyear phase-in of a brand new cost methodology through which plan funds are adjusted utilizing diagnoses solely from encounter information, which is info created by healthcare suppliers about sufferers’ medical circumstances and therapy.

In 2022, the company desires to totally transition to a danger adjustment mannequin first adopted for 2020, as required by the 21st Century Cures Act. The mannequin, known as the CMS-Hierarchical Situation Classes mannequin, provides variables that depend circumstances within the risk-adjustment mannequin and contains for cost further circumstances for psychological well being, substance use dysfunction and power kidney illness.

Totally phasing it might additionally imply that CMS would depend on encounter information because the supply of affected person diagnoses in calculating danger scores. Threat scores signify the anticipated medical value of a beneficiary and are used to regulate federal funds to Benefit plans. Typically, the sicker the individual, the upper the chance rating and, consequently, the upper the cost an Benefit plan receives. Decrease danger scores internet decrease funds for the insurer.

Traditionally, CMS has used diagnoses from inpatient information submitted into its danger adjustment processing system to complement encounter information within the cost calculation however stated it would discontinue that coverage for 2022.

The medical insurance business has lengthy railed towards the usage of encounter information to regulate their funds. They argue that the info is incomplete and sometimes inaccurate, and that its use would result in decrease funds to Benefit plans. CMS stated it has labored with well being insurers to enhance the info’s accuracy.

The proposals are included within the first of two elements of the 2022 Medicare Benefit advance discover. The second half, which offers with deliberate modifications to capitation charges and different danger adjustment methodologies, has not but been launched.

In mild of the COVID-19 challenges that insurers are coping with, CMS printed the primary a part of the advance discover about three months sooner than it has in earlier years to present well being plans extra time to arrange their bids for 2022, that are due early June 2021. CMS stated additionally it is contemplating publishing the ultimate charge announcement in mid-January fairly than April, per typical.


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