How COVID-19 is Impacting Risk Adjustment and Telehealth

While the ongoing public health emergency continues to place a significant toll on our entire healthcare system, it has disproportionately affected the health of the Medicare-age populations.

At the time of this blog post, the Centers for Disease Control and Prevention (CDC) is reporting that 8 out of every 10 COVID-19-related deaths in the United States are among adults 65-years though they represent 80% of the total COVID-19-related deaths. Aside from holding the highest fatality rate, many other disparities are facing enrollees, including:

• A lack of access to pharmacies due to restrictions and limitations
• Missed preventative services and screenings
• Delayed wellness visits and other treatments and services vital to the most vulnerable populations

This underutilization and delays in services for MA beneficiaries is not only going to have a negative effect on the health of this population, but also on Risk Adjustment Factor (RAF) scores. As risk scores are expected to decrease for both MA plans and the commercial HHS model, identifying and addressing documentation and quality gaps will be essential. That’s in no small part because our ability to uncover the most accurate risk picture will be vital to obtaining the necessary reimbursement.

Significant decreases in face-to-face visits affecting opportunities to document diagnoses, coupled with facilities struggling to stay on top of the backlog of care, will undoubtedly amplify the challenges health plans are facing in forecasting and improving risk scores for 2020 dates of service.

However, the ability to utilize telehealth services to capture diagnosis for risk adjustment in CMS’s announcement released April 10, 2020 has provided a substantial opportunity to capture chronic conditions that might otherwise have gone unreported for the year. These diagnoses may be submitted to the Risk Adjustment Processing System (RAPS) and the Encounter Data System (EDS), for payment (so long as the visits meet all necessary criteria for eligibility.) Medicare will be paying for these eligible through the public health emergency through the expansion of telehealth with the 1135 Waivers.

Because of all the financial impacts and regulatory changes, we thought we’d take a closer look at what’s influencing RAF scores, the administrative flexibilities available to your organization, and what steps can be taken to mitigate the impact of underutilization. You can find it all in our new eBrief, “What Impact has COVID-19 had on Risk Adjustment?” where we also discuss:

• Which Risk Adjustment Data Validation Changes You Should Know About
• What to Expect for Star Ratings and the 2020 CMS-HCC Model
• How to Mitigate the Risk Adjustment Impacts of Your Population