Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters? 

July 13th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Categories:   Medicare Advantage   Risk Adjustment   
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As we continue to review the effects the COVID-19 public health emergency (PHE) had on our healthcare system, perhaps one of the most dramatic outcomes was the skyrocketing use of telehealth to obtain healthcare services. Telehealth services are broadly defined as audio-visual (synchronous) communication between the patient and the healthcare provider (physician/nonphysician provider [NPP]).  However, as the demand for  telehealth services increased, payers and regulatory authorities realized that beneficiaries of both ACA and MA plans experienced difficulties due to limited access to the internet and/or the ability to use this technology to complete an audiovisual encounter. As such, the 1135 waivers and the changes instituted by payers approved reimbursement for audio-only telehealth services. In other words, beneficiaries could have a telephone encounter (audio only) with their healthcare provider to discuss their healthcare needs and the providers could receive full payment for the services as a telehealth encounter, as long as the documentation supported the service provided. 

While audio-only telehealth services became a covered benefit during the PHE, CMS put limitations on using the data from those encounters for risk adjustment scoring. Medicare Advantage (MA) plans cannot use the information from these encounters to be scored for risk adjustment; however, it can be used for risk adjustment scoring of ACA plans. 

MA beneficiaries have a heightened risk of developing severe COVID-19 infections and complications, struggle more with accessing and using technology, and have a greater number of chronic, comorbid conditions that require regular medical care. To allow a mechanism of protection and access to healthcare services such as audio-only telehealth, but then restrict the use of the information gathered during that encounter from risk adjustment scoring while allowing the ACA plans to use it, has led to the submission of a letter signed by several healthcare leaders, plans, and provider groups to the Secretary of Health and Human Services, Xavier Becerra and the CMS Administrator, Chiquita Brooks-LaSure. This letter pleads for a reconsideration of the diagnoses identified in audio-only encounters as being acceptable for risk adjustment reporting. The letter includes supportive data as to why CMS should allow MA organizations to use data gathered from audio-only telehealth services and includes a request for CMS to increase the look-back period for CY 2021 to 24 months (2019 and 2020) to ensure proper risk adjustment scoring and funding of MA plans which would allow for continued care and would avoid unnecessary cost increases or benefit limitations. 

The letter includes the following facts to support their request:

  • More than 26 million seniors are currently enrolled in Medicare Advantage (MA) with more than 50% of those beneficiaries reportedly using audio-only technology to receive healthcare services
  • While Medicare has expanded telehealth services to include reimbursement for audio only, they have not yet approved those notes for risk adjustment scoring
  • A whopping 40% of MA enrollees earn less than $25,000 annually and of those, 35% do not have access to broadband internet in their homes
  • CMS allows risk adjustment from both video-enabled AND audio-only telehealth encounters for the Affordable Care Act (ACA) plans but NOT for Medicare Advantage plans

This letter was submitted on June 3, 2021, following the April 6, 2020 CMS Announcement of CY 2021 MA Capitation Rates and Part C and Part D Payment Policies, as such it may take some time for an official CMS response to be published. 

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