With the Centers for Medicare & Medicaid Services extension on claims submissions coming to an end in 2024, health plans must separate fact from fiction around proactive risk adjustment to confidently submit claims for accurate reimbursement.
For many Medicare Advantage and Program of All-Inclusive Care for the Elderly organizations, the Centers for Medicare & Medicaid Services extension on claims submissions reveals just how many lost opportunities there were for capturing more complete, accurate accounts of member conditions.
But with the extension ending, health plans are losing six months for medical record retrieval, reviews, and submissions. A three-month project likely means plans can only retrieve 70% of records versus 90% during a six-month project. This time crunch can affect coding accuracy for submissions and impact the completeness and accuracy of data reported to CMS.
With the CMS extension ending in 2024, it’s essential to consider how agile analytics — alongside consistent data review and provider engagement — can help plans confidently submit claims for accurate reimbursement by the January deadline. First, plans must separate fact from fiction around proactive risk adjustment:
To be proactive about medical record retrieval and claims submissions, plans need real-time access to member and provider data. They can leverage these insights to create quarterly analysis reports that provide comprehensive overviews of member health and provider metrics. These assessments help plans see where they can act. For example, members with certain risk adjustment factor opportunity scores would benefit from health risk assessments.
How Proactive Planning and Agile Analytics Can Support Early Claims Submissions
What does an analytics-supported risk adjustment program look like in action? Here are some strategies one of our clients adopted during the CMS extension:
An advanced analytics system supports a proactive approach to risk adjustment, leading to better retrospective results. Plans must ensure their data is accurate and complete within claims, analytics, and medical records to get the most out of an analytics solution. Doing so can streamline the risk adjustment process, support customized care delivery to members, and strengthen provider relationships.
Meleah Bridgeford is the senior director of risk adjustment analytics at Episource, a leading provider of risk adjustment solutions and services for health plans and provider groups. She has over 10 years of experience within healthcare organizations as well as vendor and consultant organizations.