I’m a huge fan of the World Cup. I love the energy and excitement of dozens of countries gathering to square off against one another. Stadiums are packed with chanting fans willing their favorites to succeed, and the play rarely disappoints.
The games are extremely competitive, and the margins are narrow. More than half of the games are won by one point or in a shootout. This makes understanding the rules and working within them critically important – a lot like risk adjustment. Admittedly, a topic that stirs less passion and enthusiasm, but, like the World Cup, very little separates winners from losers.
CMS Risk Adjustment Changes Are Rewriting the Rules of the Game
A feature of soccer matches that surprises casual American viewers is the tendency of players to throw themselves to the ground and writhe in agony to persuade the referee that, clearly, a sin against god and man had been leveled against them.
One rule change implemented this time around is that players requiring medical attention must step off the field for one minute. The idea is to streamline the game and reduce the temptation to slow play in a cynical attempt to draw a foul.
Similarly, CMS has worked hard to reduce the incentives associated with making more of something that it is. Version 28 is fully operational this year. That means there is less distinction between mild, moderate, and severe presentations of disease.
“I think CMS has been pretty consistent with their message of ensuring that coding is not some form of a gamified, competitive advantage for people,” said Alignment Healthcare’s John Kao.
Coding Accuracy, Chart Reviews, and the Push for Consistency
Another rule that befuddles viewers is offsides. As a kid, I remember a soccer referee grabbing me by the shoulder and pushing me forward and back, trying to explain the rule. “This. This is offside.” This year, new technology, like that used in tennis, keeps an eagle eye on where everyone is lined up. The intent is to maintain consistency.
Like the new monitoring technology, CMS is aiming to improve consistency and accuracy by working to “exclude diagnosis codes added for enrollees based on chart review records that are not linked to an encounter with a health care provider (referred to as “unlinked” chart reviews)” in 2027. This more closely aligns care delivered with what is coded on claims. Upon review, CMS found that plans are far more likely to add diagnoses than remove them during a chart review.
RADV Audits and the Growing Scrutiny on Medicare Advantage Risk Adjustment
VAR (video assistant referee) presents an obvious analogy to audits and the near-endless scrutiny of past events. In practice, VAR seems to only deepen frustration with calls made or not made on the field – Ask Egypt. Everyone cringes when the referee trots to the side for a look at the monitor.
CMS has clearly prioritized cracking down on fraud. As they self-proclaim, “CMS is crushing fraud, waste, and abuse to protect Americans.” Part of the effort includes the Office of the Inspector General ramping up scrutiny of risk adjustment through RADV audits and, in particular, focusing on high-variation conditions, like COPD and CHF. Presumably, this will lead to more consistent coding.
Why Annual Wellness Visits Are the Set-Piece of Risk Adjustment
Another change in the way play at this World Cup is the emphasis on set-pieces. For several years now, Premier League teams, notably Arsenal, have focused on corner kicks, long throw-ins, and penalty kicks. The number of goals associated with such plays have increased from 20% to 30% in recent seasons.
Similarly, the annual wellness visit is the set-piece play of risk adjustment. It is scripted, defined, and can be honed with practice. AWVs have the added benefit of helping to close gaps in care and build connections between members and PCPs.
Three Ways Health Plans Can Gain an Edge
Plans, like teams on the pitch, have to take the world as it is, adapt to the new environment, and take action to achieve risk adjustment success.
- Promote the AWV: This really is a discrete event that can be maximized to generate a host of benefits. It connects members with PCPs, closes gaps, and improves complete and accurate risk adjustment. At Engagys, we’ve worked with plans to create segments of members and deliver segment-specific content that doubled the number of members completing in-home AWVs. This is the sort of gain at the margin that can turn a mediocre season into a championship one.
- Connect members to PCPs: Access to primary care can be a struggle for many members, particularly those facing socioeconomic barriers. We helped one client increase the number of AWVs completed in the office by 8% by promoting the transportation benefit to dual-eligible members. We started by identifying areas with gaps in access and then revised the communications to help members sort through what is a complicated benefit. Medicare covers the first block of rides before Medicaid steps in. These are often two different vendors who struggle to share information with the plan.
- Maximize operations: Plans can examine their processes to find opportunities and eliminate weaknesses. Our work with one plan initially delivered dramatic increases in the number of members engaging with outbound calls to schedule AWVs. However, the solution was like squeezing a balloon. As the number of inbound calls rose, so did the number of abandoned calls. Interested members were walking away and required additional work to streamline workflows to improve throughput and get the right number of agents in place.
Winning Risk Adjustment
The changes at CMS, like all of those at the World Cup, are designed to speed play, improve transparency, and protect the beautiful game. Whether the intended consequences are realized is something for pundits and fans to debate for years to come.
As we’ve seen at the World Cup, margins are tight. Winners take advantage of every edge that they can find. Similarly, plans need to stay focused and continually practice to achieve peak performance.
If you’re ready to win at risk adjustment, let’s talk.
Watch the Full Video Interview for Risk Adjustment Lessons from the World Cup
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