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How Will the End of the CMS Submission Deadline Extension Affect Your Risk Adjustment Program?


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:

  • Myth 1: Building medical record retrieval lists too early won’t factor in claims lags.
    Reality: The average claims lag is one to two months. With the increased use of electronic medical record systems, plans can enjoy continuous record retrieval processes, further reducing claim lag times. Additionally, the number of claims that are delayed for processing is typically small, with a minimal overall impact on risk score accuracy. To illustrate, our analysis at Episource found that the average risk score increased from 0.2% to 0.5% between when the typical medical record retrieval list was created and three months prior.
  • Myth 2: Starting medical record review early will impact the final payment.
    Reality: By ensuring all medical records from 2022 dates of service are reviewed and submitted before the September sweep, health plans can see impacts on their 2023 final payments and their 2024 initial payments. This will enable them to plan forward, establish funding for more programs to optimize member health and care, and support further risk adjustment strategies.
  • Myth 3: Early medical record retrieval will increase provider abrasion.
    Reality: By consistently reviewing member medical record data throughout the year, plans can proactively identify members with multiple hierarchical condition categories or incomplete diagnoses and create targeted medical record retrieval lists. Having this information early in the calendar year will help providers understand their patient populations to improve and streamline care coordination. Plus, providers will appreciate steadier streams of medical record requests.

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:

  • Building strong provider relationships. The health plan holds quarterly meetings with its provider networks. The discussion topics vary; for instance, they might discuss provider group metrics or opportunities for improvement of care.
  • Creating targeted vendor medical record retrieval lists. With Episource Analyst, our client customized its retrieval lists, focusing, for example, on commonly over- or under-coded conditions or target members for specific programs to benefit their health.
  • Creating a dedicated payer plan staff. The health plan has a dedicated team that works on medical record retrieval barriers and assists with retrieval. Because of its solid provider relationships, the plan has accurate contact and location information for providers, making it easier for the team to retrieve medical records successfully.
  • Going above and beyond diagnosis submission minimums. The health plan submits diagnosis data weekly to CMS. This approach allows it more time to update information shared with vendor partners. It also regularly reviews data to better understand its members and providers.

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.

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