A recent HHS Office of Inspector General (OIG) report paints a misleading picture of in-home health risk assessments (HRAs) in the Medicare Advantage (MA) program. Here are the facts:
CMS ‘does not concur’ with key OIG recommendations, raises concerns about report’s flawed methodology.
- OIG’s report
does not document a single inappropriate code submitted or payment made to an MA plan, the Centers for Medicare and Medicaid Services (CMS) points out.
- CMS notes that OIG has “not conducted medical record reviews of the diagnoses that came from visits that may have contained an HRA and have not concluded that these diagnoses are not accurate.”
- CMS does “not concur with [OIG’s] recommendation to restrict the use of diagnoses reported only on in-home HRAs or chart reviews linked to in-home HRAs for risk-adjusted payments.”
- CMS “also states that the lack of a definitive method for identifying in-home HRAs raises challenges in any effort to reconsider allowing these diagnoses for risk adjustment.”
- CMS reiterates that the agency has robust systems in place to closely administer coding practices and ensure data submitted through the encounter data system meet program rules.
- All of these diagnoses are subject to CMS risk adjustment requirements, including that diagnosis codes are documented in the medical record and are documented as a result of a face-to-face visit with a clinician.
- CMS conducts audits of diagnoses submitted for risk adjustment and all MA plans are subject to these Risk Adjustment Data Validation (RADV) audits.
- CMS points out that other report recommendations are already reflected in existing policy – in one such case stating CMS “has implemented this recommendation, and considers it closed.”
HRAs are one of many tools MA plans use to support patients, identify chronic conditions early, and prevent these conditions from becoming more serious or costly in the future.
- Whether they occur in the patient’s home or in a clinical office setting, the HRA offers an opportunity for the health plan and provider to obtain a complete evaluation of the patient’s physical, behavioral, and mental health needs, medications, health risks, and environmental factors that affect health.
- In many cases, CMS requires MA plans to conduct HRAs – for example, for enrollees in Special Needs Plans or those enrolled in Financial Alignment Initiative demonstration plans. And CMS considers HRAs a best practice for all MA plans and their enrollees.
- In-home HRAs “identify and meet the medical and non-medical needs of vulnerable beneficiaries in their own homes and communities to impact health outcomes,” a report by Manatt explains. “For [vulnerable] populations, the [in-home HRA] can help remove barriers to care and improve access to preventive care services while fostering long-term care relationships, which are essential in ensuring equitable access to care and improving beneficiaries’ long-term outcomes.”
HRAs are a small part of MA payment and CMS uses a range of tools to ensure payment accuracy in MA.
- According to OIG’s own estimates, payments associated with in-home HRAs and HRA-linked chart reviews represent less than one percent of total MA payments.
- Not all diagnoses identified through an HRA or chart review are taken into account for risk adjustment payments. For example, if an individual has multiple diagnoses within the same Hierarchical Condition Category (HCC), only the most severe condition is counted for risk adjustment payment.
- Medical loss ratio (MLR) rules ensure at least 85% of MA plan revenue is used to pay claims or for quality improvement programs. MA plans must return any excess funds to the government.
For more information on HRAs in MA, click here.