Medicare Risk Adjustment (MRA)

Medicare Risk Adjustment (MRA)

Risk adjustment is a process that CMS uses to level the playing field regarding the reporting of patient outcomes and Medicare reimbursement based upon patient health status. It enables health plans to be paid appropriately based upon members' overall health.

How does risk adjustment work?

Patient health risks are adjusted using a number of variables, including age, gender, previous health history, and the presence of chronic conditions. This formula yields a member risk score, which is used in calculating payment to a health plan.

2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent based on the RAPS files. With this transition, it is critical that health plans ensure that their RAPS files and Encounter files are in sync. Oh- and the vendors are on the hook for this too.

For some, the financial and operational impact of the transition from RAPS files to EDS files for risk adjustment is still a mystery. On October 23, CMS announced further guidance regarding RAPS and EDS Submissions.

There were three key elements:

1). The addition of diagnoses submitted after the risk adjustment deadline for payment year

2). The submission of HIPPS Codes for CAH’s

3). The use of default NPIs for atypical providers.

Your organization not only needs controls on the front end, it needs quality oversight and standard operating procedures in place to manage the file return elements from CMS.

Providers should be able to report/understand  the analysis of their practice:

§  Operational Assessment Report – Outline of the processes that the health plan currently has in place for RAPS/EDS file submissions, returns and error resolution, providing areas of opportunity for improvement.

§  Variation Analysis Review – Review of findings, outlining instances for potential inaccuracies and risks associated with the health plans current methodology and processes applied to the internal variation analysis.

§  Discrepancy Reports – Identifies opportunities to improve completeness and accuracy of each submission to CMS.

§  Encounter File Member Analysis – Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the RAPS file member analysis.

§  RAPS File Member Analysis – Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the encounter file member analysis.

How to perform/complete the MRA’s ?

HPP AccuChecker is proud to introduce MCAR REPORTS a complete set of management reports for IPAs, MSOs and PCP Practices that have Risk Agreements with HMOs Plans. The MCAR Reports give you complete awareness over what is happening with every HMO Plan that your organization participates in risk operations.

MCAR - MANAGED CARE REPORTS is an online service available created from data files downloaded from HMOs servers. Within 24 to 48 hours our team produces all reports needed to manage your risk business. MCAR Reports are viewed from our secured HIPPA compliant servers however most reports are downloadable in EXCEL format files.

MCAR Reports services can range from only generating reports to having our management team assisting clients in managing the risk operations.

Clients can select MCAR Report services “A LA CARTE” choosing monthly reports needed and/or consulting services they prefer.

 

FOR MORE INFORMATION

HPP Management Group, Corp.

5201 Blue Lagoon, Suite 800

Miami, FL 33126

Phone: (305) 227-2383 or 1-877-938-9311

Email: pesilverio@hppcorp.com

Website: http://www.accuchecker.com