White Paper: New Risk Members and How to Impact Them - Advalent
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White Paper: New Risk Members and How to
Impact Them
© 2019 Advalent, Inc. - All Rights Reserved
Preparing Early New Members
The key to success for any new or existing New membership for the MAO can result
Medicare Advantage Organization (MAO) is in statistically lower risk scores due to
largely built around the strength of your Risk differentiating factors. Members coming
Adjustment strategy and platform. The from a traditional Fee for Service (FFS)
knowledge base and expertise within the Medicare benefit will typically have a lower
organization and/or delegated RA vendor is risk score. The reason for the lower score
paramount to understanding the complexities could be that there was a lack of incentive
of submission, coding, membership variation, contracting for the physician and/or lack of
financial projections and timing. This white education provided by the MAO plan for the
paper will examine the following in detail: physician around specific diagnosis capturing.
• When do MAOs receive payment? Nevertheless, members who opt to switch
• What members can be impacted? from another MAO plan will not necessarily
• Why is it important to know where your have a better risk score. If a member has
membership came from? moved from a plan that has not built a
• What strategies can be made to make robust Risk Adjustment program and/or failed
earlier impacts? to create efficient submission strategies, the
• Why is the shape of Risk Adjustment new plan can still feel the negative effects of
changing rapidly? that member initially. However, due to a rule
change from CMS in a Memo dated June 20,
2017, plans can submit retrospective diagnosis
Risk Adjustment Payment codes within a RAPS submission from a
Each member within a MAO is risk adjusted member who was enrolled with a different
per The Centers for Medicare and Medicaid Parent Organization in order to adjust and
Services (CMS) program. Every individual will accurately capture the new members’ risk
be designated a risk score calculated based scores
on diagnosis, demographics, and factor types.
These payments make up almost all the plan’s The tables below and on page 2 demonstrate
annual revenue. How they impact that revenue the differences between impacting new
will be determined on the strategy and members for both situations.
execution of their Risk Adjustment plan. Each • Figure 1.1 - Future Pay Year (PY) 2020 & 2021
new member or returning member can be FFS member entering the MAO market.
impacted in different ways to reach the • Figure 1.2- Future PY2020 & 2021 for
optimum risk score. transitional MAO member
Figure 1.1
Page 1Figure 1.2
Affecting Payment
There are three approaches to consider when New to Medicare Member
receiving new membership which center 1. PY2020 Beginning RAF: Based on
around the different types of members. Let’s demographics only.
look at the example of new membership for 2. PY 2020 Mid-Year RAF: Based on
January 2020. demographics only.
3. PY 2020 Final RAF: Based on demographics
FFS Member only.
1. PY2020 Beginning RAF: Based on 4. PY 2021 Beginning RAF: Based on diagnosis
diagnosis from their FFS dates 7/1/18 for RAPS/EDPS 7/1/19 through 6/30/20.
through 6/30/19. This only applies if the member has had a
2. PY 2020 Mid-Year RAF: Based on diagno- full 12 months of Medicare eligibility. If the
sis from 1/1/19 through 12/31/19 only FFS member became eligible any time after
claims. Cannot retrospectively audit. January, the “New Enrollee” flag can be
3. PY 2020 Final RAF: Based on diagnosis from active up to 24 months and the pan will
1/1/19 through 12/31/19 only FFS claims. continue to receive demographic payment.
Cannot retrospectively audit.
4. PY 2021 Beginning RAF: Based on diagnosis
for RAPS/EDPS 7/1/19 through 6/30/20. Strategy for Impact
This is the first instance the MAO can affect Regardless of the different reimbursement
payment on these members. rates and timing on these members, there are
strategies that align to affect these members
MAO Member currently and in the future. Advalent’s
1. PY2020 Beginning RAF: Based on diagnosis RISK360TM will allow payers and risk bearing
from their previous MAO submitted RAPS/ providers to not only identify suspect
EDPS within 7/1/18 through 6/30/19. conditions, but also assign the correct
2. PY 2020 Mid-Year RAF: Based on diagnosis interventions for each HCC gap to address
from their previous MAO submitted RAPS/ considering their propensity of closure during
EDPS within 1/1/19 through 12/31/19. Can the required coverage periods. This allows for
retrospectively audit. These members for both prospective and retrospective tactics to
extra reimbursement based on CMS ruling. align regardless of the new enrollee. This
3. PY 2020 Final RAF: Same ruling as Mid-Year approach alone will generate a superior ROI
payment for these members if new plan can with high predictability and drive sustainable
have access to member chart information. financial improvements.
4. PY 2021 Beginning RAF: Based on diagnosis
for RAPS/EDPS 7/1/19 through 6/30/20.
This is the first instance the MAO can affect
payment on these members.
Page 2Submission of Data
There is also the very important task of data Figure 2.1 below shows the current PY2019
submissions and how to accurately run various blended RAF calculation and the two different
calculations and reconciliations for both HCC models and mappings used to determine
payment and data compliance. The induction a blended score. The composite model
of Encounter Data Submission (EDPS) over the calculations and submissions are becoming
last few years has made it extremely important progressively complicated with each new roll
to have a strong submission platform to deal out as CMS transitions from a RAPS to EDPS
with the complexities that accompany EDPS world.
submissions. Various blends and model
versions have been released within the last few For PY2020 the EDPS execution risk increases
years which have created a heavy burden on once again with a heavier weight placed upon
payers to accurately project financial accruals. encounters and a new count variable model
CMS has continued with their quest to place introduced. Figure 2.2 below explains the
big changes in the model over the coming breakdown for the following year.
years.
Figure 2.1
Figure 2.2
Execution Risk Factors
The time to act is now. With an increasing solution that encompasses RAPS, EDPS,
transition to encounter data, health plans Medicaid, EDGE and APCD risk adjusted
across the United States are focusing more submissions. It supports both inbound and
time and energy into these submissions. outbound data validation, production
Currently, error rates in submissions are workflows for error correction, and reporting
ranging from 3%-15% within plans. These rates alerts with revenue risk adjusted forecasting,
are increasingly worrying as EDPS still allows as well as EDPS/RAPS reconciliation.
for RAPS Inpatient records to be calculated
within encounter reimbursement blends, but Contact Advalent today to discuss the future
that will not always be the case. of Risk Adjustment and how we can help take
your plan to the next level with our
Advalent’s Encounters PlusTM Risk Submissions industry-leading Risk Adjustment solution
platform is a HIPAA-compliant, cloud-based platform.
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