2022 Medicare Advantage Advance Notice: CMS reveals plans to fully use encounter data for risk adjustment

The Centers for Medicare & Medicaid Services (CMS) on Monday released Part 1 of its 2022 Advance Notice, which outlines changes to Part C CMS-Hierarchical Condition Categories (HCC) risk adjustment model and the use of encounter data for 2022. CMS intends to finalize the payment policies by April 5, 2021. CMS said in a fact sheet that it issued Part 1 of the 2022 Advance Notice earlier than usual so Medicare Advantage (MA) organizations and Part D sponsors have more time to factor in the changes as they prepare their bids for 2022. What you need to know Here are the key changes outlined in the proposal: CMS intends to fully phase in the CMS-HCC model in 2022: This is a change from the mix for 2021 of 75 percent of the risk score calculated using the 2020 CMS-HCC model and 25 percent of the risk score calculated using the 2017 CMS-HCC model. Under the proposal for 2022, CMS will calculate 100 percent of the risk score using the 2020 CMS-HCC model.

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 Highlights from 10 RISE National sessions: Regulatory updates, strategies to improve Star ratings, risk adjustment, payer/provider collaboration

Did you miss last month’s RISE National 2020 virtual conference? Here’s a summary of a few of the sessions. OIG's work on vulnerabilities with Medicare Advantage. Megan Tinker, senior advisor for legal affairs, and San Le and Jacqualine Reid, both social science research analysts at the Office of Inspector General, gave an excellent presentation, providing attendees with the findings of recent evaluations and investigations aimed to ensure that beneficiaries of the Medicare Advantage (MA) program get the services they need and funds aren’t being diverted through fraud, waste, and abuse.

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 RISE National 2020: Keynotes inspire with life stories that show the power resilience, courage, and kindness under the worst of circumstances

Phenomenal keynote speakers took the virtual stage over two days at the annual event, RISE National 2020, and offered stories of hope and perseverance during the darkest of times. In a world of ethical dilemmas, John Quiñones lights the way to the moral high ground. Weeks after speaking at RISE’s National Summit on Social Determinants of Health, Emmy Award winning journalist John Quiñones returned as the keynote speaker for RISE National 2020 but with a different message for the audience. As the creator and host of the long-running, hidden camera show, What Would You Do?, Quiñones has become the face of doing the right thing when confronted with moral and ethical dilemmas.

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 Provider/payer collaboration imperative for improved patient care

Leading experts in the Medicare Advantage and Affordable Care Act market continue to call for collaboration between providers and payers. Take an inside-look at their tips to bridge the gap. Provider/payer collaboration was a consistent theme throughout last month’s virtual conference, RISE National 2020. During the two-day mega-conference, industry leaders shared insights and best practices for providers and payers to remove existing barriers, improve risk and quality, and work together in a virtual world. Here are three of the biggest takeaways.

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RISE National: New name, new virtual format – same amazing content

The annual event, formerly known as RISE Nashville, will now stream live on June 29-30 with pre-conference workshops on Friday, June 26. Designed to be highly interactive and hosted on a state-of-the art digital platform, RISE National 2020 will deliver the same high-quality content and engagement opportunities that attendees have come to expect from RISE live events. Here’s a look at what you can expect at this year’s mega-conference for professionals of all levels in the Medicare Advantage and Affordable Care Act market.

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Learning at its finest: 5 reasons to attend RISE Nashville 2020

Now in its 14th year, RISE Nashville has become the must-attend event for the latest information and strategies for risk adjustment, quality, Star ratings, CMS and OIG RADV audits, predictive analytics, payer-provider collaboration, social determinants of health, value-based care, member engagement, and physician engagement. In 2019, more than 1,400 attendees from 587 organizations joined RISE in Nashville for unmatched learning and networking opportunities. Here’s what you can expect at next year’s event...

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 CMS, OIG officials to speak at RISE Nashville 2020 

RISE Nashville 2020 attendees will hear the latest policy updates from representatives of CMS when the annual conference convenes March 15-17, 2020 at Music City Center.

Erin Sutton, deputy director for the Payment Policy and Financial Management Group, and Kelly Drury, director, division of risk adjustment operations, for CMS, will join a roster of more than 100 speakers at the annual Medicare Advantage mega conference. Representatives from the U.S. Department of Health and Human Services’ Office of Inspector General will also be on hand to offer an overview of the OIG’s work to combat fraud, waste, and abuse in Medicare Advantage. 

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 The Supreme Court won't fast-track ACA legal challenge before November elections  

The Supreme Court has no plans to take up a pivotal case involving the Affordable Care Act (ACA) before the presidential election in November but also didn’t rule out a full review in the future. The Supreme Court on Tuesday denied a motion to rush a case that challenges the constitutionality of the Affordable Care Act (ACA). The one-sentence decision means the earliest the high court would hear the case is during their next term, which begins October 1. However, the Supreme Court could still deny the petition to review the case, which would send the case back to U.S. District Judge Reed O’Connor, who ruled in December 2018 that the ACA became unconstitutional when Congress enacted President Donald Trump’s tax overhaul. The tax plan eliminated the financial penalty of the law’s individual mandate, which required most United States citizens and legal residents to obtain health insurance or pay a penalty.

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 Federal court reinstates HHS risk adjustment methodology  

The United States Court of Appeals for the Tenth Circuit has reversed a district court decision that found flaws in the Department of Health & Human Services’ (HHS) risk adjustment formula. The decision is a blow to small insurers, particularly the New Mexico co-op that argued in a lawsuit that the way the federal government implemented the Affordable Care Act risk adjustment program “brutally penalizes new innovative, low-cost insurance companies and flouts Congress’ intent in enacting the ACA.”

The court decision, first reported by Katie Keith in the Health Affairs Blog, was passed down on Dec. 31, 2019. The three-judge panel disagreed with a previous ruling by the district court in New Mexico that struck down the use of the statewide average premium in the payment transfer formula for the 2014-2018 benefit years. The latest ruling reinstates HHS’ risk adjustment methodology for 2014 through 2016. The panel determined that the challenges over the rules for 2017 and 2018 methodologies are moot because HHS issued new rules for those benefit years.

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 3 top health care stories in 2019 that will reverberate in 2020  

RISE looks at three health care headlines in 2019 that will have implications for health plans in 2020.

The uncertain future of the Affordable Care Act

The fate of the Affordable Care Act (ACA) was uncertain as we headed into 2019 and will end the year in the same way.

Last year U.S. District Judge Reed O’Connor of the Northern District of Texas declared the entire health care reform law as invalid but allowed the law to remain in effect while the case was appealed. He sided with Republicans, who argued that the ACA became unconstitutional when Congress enacted President Donald Trump’s tax overhaul and eliminated the provision as part of the law’s individual mandate that required most Americans to purchase health insurance or pay a penalty.

Increased focus on social determinants of health

Another top story from 2018 continued to make headlines in 2019 and will likely do so in the upcoming year: the industry’s focus on the conditions in the places that people live, learn, work, and play that affect health risks and outcomes. 

Unexpected findings in Medicare shopping and switching behavior

Approximately 10 percent of Medicare members switched plans or insurers during the 2019 Annual Election Period (AEP), according to Deft Research’s 2019 Medicare Shopping and Switching Study. Half of the switchers were happy with their 2018 coverage but shopped around for better coverage in 2019 anyway. The findings mean MA plans need to add or increase benefits to keep existing members and attract new ones.

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 OIG questions $6.7B in risk adjustment payments to Medicare Advantage plans, but RISE argues methodology is flawed 

A new report from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) raises concerns that Medicare Advantage (MA) plans may use chart reviews to inflate risk-adjustment payments from the Centers for Medicare & Medicaid Services (CMS). But the OIG’s methodology and findings don’t add up, according to Sean Creighton, managing director, Avalere, and chair of the RISE Risk Adjustment Policy Advisory Committee.

The OIG conducted the investigation over concerns that MA organizations may use chart reviews to increase risk adjustment payments inappropriately.

The agency reviewed 2016 MA encounter data for diagnoses only reported on chart reviews and found that in 99 percent of the cases, MA plans used chart reviews as a tool to add, rather than to delete diagnoses such as cancer, diabetes, and heart disease.

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 The FFS Adjuster matters for accurate Medicare Advantage payment: An examination of the methodology and evidence behind a regulatory proposal to eliminate the adjuster 

Eliminating the Fee-for-Service Adjuster from the Risk Adjustment Data Validation methodology would likely have significant implications for plan payment and could change plan incentives and behavior, including plans’ willingness to assume the risk of participating in the program, writes Sean Creighton, managing director of Avalere, who also serves as a RISE board member and the chair of the RISE Risk Adjustment Policy Advisory Committee.

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Emmy-Award winner John Quiñones named keynote speaker at RISE Nashville 2020

John Quiñones has been added as the third keynote speaker for RISE Nashville 2020, which will take place March 15-17 at Music City Center.

As host and creator of What Would You Do?, the highly-rated, hidden camera ethical dilemma newsmagazine, Quiñones has become “the face of doing the right thing” to millions of fans. It’s a role that he has enthusiastically embraced off camera, with a popular book and inspirational keynote presentations that challenge both business and general audiences to examine the What Would You Do? moments we face every day.

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Award-winning Celebrity Chef Jeff Henderson to share his inspirational life story, lessons for success at RISE Nashville 2020

You may know him as the star of the nationally syndicated series, Flip My Food with Chef Jeff, where he prepares healthier versions of favorite family and restaurant recipes. But before he discovered his passion for culinary arts, Jeff Henderson was a drug dealer and spent nearly a decade incarcerated in federal prison. He’ll tell his emotional story of how he overcame all odds during a keynote presentation at RISE Nashville 2020, March 15-17, at Music City Center in Nashville.

“During the early part of my life I was in survival mode. I was trying to figure out how to help my mother, who was a single parent, trying to figure out how to survive, how to keep food on table, how to go to school, how to figure out what my dream was. My dream was one day to be rich so I could help my mother buy a house,” he says.

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RISE Nashville 2020: Keynote Allison Massari to offer an inside look into the patient experience


Nearly 22 years ago an automobile accident left 50 percent of Allison Massari’s body covered with second- and third-degree burns. The pain she endured was excruciating, and she spent years in recovery and rehabilitation. She needed to heal physically, emotionally, mentally, and spiritually. Massari will talk about her experience and what she describes as compassionate care and the art of patient-centered care during a keynote presentation at RISE Nashville. 

"Compassionate care is not just about being kind," she explains. "Being an expert in your job is compassionate care, and being fully present in your tasks, and triple-checking your work is compassionate care. Keeping an organization financially healthy so you can be there for your patients is compassionate care...Everything trickles down to the patient and is a form of empathy."

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Brain Scientist Dr. John Medina returns to lead pre-conference workshop at RISE Nashville 2020 

Back by popular demand! Brain Scientist Dr. John Medina, last year's top keynote speaker at RISE Nashville, will return for our 2020 conference to lead a half-day workshop on the brain science behind delivering powerful and engaging presentations. Medina, author of the New York Times bestseller, “Brain Rules: 12 Principles for Surviving at Work, Home and School,” will discuss brain processing and offer practical advice on how to make presentations clear and compelling. The workshop will take place 1 to 3 p.m., Sunday, March 15 at RISE Nashville 2020, Music City Center in Nashville. Space is limited.

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