Risk adjustment is important to health plans as it determines how much they will be paid in the Affordable Care Act market, managed Medicaid and Medicare Advantage plans.
Under the coronavirus pandemic, risk-adjustment calculations have become a cause for concern.
One question is how COVID-19 claims will affect risk calculations. Another is how the disruptions to regular care in 2020 will lower the prospective risk scores used to pay MA plans in 2021.
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As in other areas of care under the new normal, telehealth has provided a way forward.
Vatica Health specializes in risk adjustment, especially for insurers that offer Medicare Advantage plans. When the COVID-19 pandemic shut off in-person visits and reduced traditional care, the company announced a PCP-centric solution for primary care telehealth that boosted proper risk adjustment.
The solution came about as a direct response to COVID-19 and the expanded use of telehealth allowed by the Centers for Medicare and Medicaid Services.
WHY THIS MATTERS
Risk adjustment is a statistical process used by plans that takes into account the underlying health status and spending of plan enrollees when looking at outcomes or costs.
For Medicare Advantage plans, it determines the capitated payments paid by CMS. MA payment premiums are established by both region and a risk score.
Also, physicians in the MA program must document the underlying conditions each patient has in order to determine the level of reimbursement for that patient. Medicare requires that this be done in person or using telehealth that has both an audio and video component.
Before COVID-19, Vatica was paid by health plans to send nurses into doctors' offices to make sure coding for medical treatment was accurate in its documentation in the electronic medical record.
When the pandemic shut off access, health plans faced a reduced ability to risk adjust their membership.
Vatica contacted its 700 primary care providers to do risk adjustment remotely, according to CEO Dr. Hassan Rifaat. Already 81% or providers were ready for telehealth. The company established remote access to EMRs, and also helped providers that weren't ready for telehealth to set up both audio and video access with patients.
Vatica nurses are not part of the live telehealth encounter. After the provider has documented the encounter, that information goes into the EMR and it is accessed remotely by company clinicians.
"The reason risk adjustment is so important, it's critical the health plan receive the proper premium in the membership they serve." Rifaat said.
Traditionally, risk adjustment is done through a retrospective chart review long after the encounter.
THE LARGER TREND
When CMS allowed for more than 80 services to be conducted by telehealth, it also made temporary changes to pay for the virtual visits at the same rate as in-person visits while the coronavirus emergency remained in effect.
Long-term, with a soft reopening of medical practices, telehealth remains in place, along with in-person visits, and it has a place long-term, Rifaat said.
ON THE RECORD
"At a time when keeping beneficiaries healthy is critical and every dollar of premium is more important than ever, it's essential that health plans have risk adjustment and quality of care partners that enable providers to engage and manage the most vulnerable members with chronic conditions across all lines of business," said Dr. Hassan Rifaat, CEO of Vatica Health.
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