By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    bowl of vegetable salad
    Raw Foods: benefits and harms
    November 9, 2021
    pros and cons of the keto diet
    Read This Before You Follow the Keto Diet
    May 18, 2022
    spinal cord injuries
    4 Potential Causes of Spinal Cord Injuries (and How to Seek Compensation)
    May 25, 2022
    Latest News
    5 Steps to a Promising Career as a Healthcare Administrator
    July 31, 2025
    Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
    July 20, 2025
    How Probate Planning Shapes the Future of Your Estate and Family Care
    July 17, 2025
    Beyond Nutrition: Everyday Foods That Support Whole-Body Health
    June 15, 2025
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    Effective Healthcare Requires a Social Approach
    June 15, 2015
    CCBHCs
    2016 Excellence in Behavioral Health Program Design
    February 23, 2016
    conducting Clinical Trial
    5 Tips for Conducting a Clinical Trial
    April 21, 2024
    Latest News
    How IT and Marketing Teams Can Collaborate to Protect Patient Trust
    July 17, 2025
    How Health Choices and Legal Actions Intersect After an Injury
    July 17, 2025
    How communities and healthcare providers can address slip and fall injuries with legal awareness
    July 17, 2025
    Let Your Lawyer Handle the Work Before You Pay Medical Costs
    July 6, 2025
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: CMS for Medicare Advantage Risk Adjustment Update
Share
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Policy & Law > CMS for Medicare Advantage Risk Adjustment Update
Policy & Law

CMS for Medicare Advantage Risk Adjustment Update

philcsolomon
philcsolomon
Share
6 Min Read
CMS
SHARE

 

CMS

Medicare’s Recovery Audit Contractor (RAC) program was implemented nationwide for Medicare Parts A and B in January 2010 

 

More Read

Driverless Autos
Who or What Is Det Norske Veritas?
Do Republican Presidential Candidates Have any Good Ideas on Health Care?
Small Business Coalition Launches National Anti-Reform Effort
Is $10,000 a Lot of Money? Not in Health Care.

CMS

Medicare’s Recovery Audit Contractor (RAC) program was implemented nationwide for Medicare Parts A and B in January 2010 

The Affordable Care Act calls for the program to be expanded to cover Medicare Advantage plans, and last month CMS released a draft Scope of Work to “solicit comment on, and interest in CMS entering into a contract with RACs to identify underpayments and overpayments, and recouping overpayments associated with diagnosis data submitted to the Centers for Medicare & Medicaid Services (CMS) by Medicare Advantage Organizations.”  Up to now, CMS has conducted limited audits of MA Plans covering only about five percent of Medicare Advantage Organization Contracts.  The Scope of Work document outlines plans to significantly expand those audits by contracting with RACs, who currently audit only Medicare Part A & B payments.

RACs are paid based on amounts recovered and currently earn anywhere from nine to 12.5 percent of recouped overpayments on average.  Many providers view RACs as administrative burdens and argue that independence and fairness cannot be achieved in a system in which auditors have a financial incentive to find errors.  On the other hand, CMS contends that RACs help to ensure taxpayer money is being spent appropriately.

Medicare Advantage plans (sometimes referred to as Medicare Part C) are Medicare-approved private health insurance plans offering seniors an alternative to traditional Medicare.  In recent years they have signed up more than 17 million members, about one-third of those eligible for Medicare.  Medicare Advantage plans provide all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage and generally offer additional benefits, such as vision, dental and hearing, and many include prescription drug coverage.

Pricing to enrollees varies by plan provider, based on the services and type of plan chosen.  Since 2004, the government has paid the health plans using a risk score it calculates for each patient based on diseases reported by the health plans. Medicare expects to pay higher rates for sicker people and less for those in good health.  But overspending tied to fast-rising risk scores has cost taxpayers billions of dollars in recent years, as the Center for Public Integrity reported in a series of articles published last year, leading to widespread suspicions that some risk scores are being purposefully inflated.  CMS relies on diagnosis information reported by Medicare Advantage organizations to determine the health conditions for each beneficiary.  CMS then uses the Hierarchical Condition Category risk adjustment model to calculate risk scores.

All diagnosis codes submitted to CMS for Medicare Advantage risk adjustment must meet a number of requirements.  They must:

  • Be documented in the medical record
  • Be documented as a result of a face-to-face visit
  • Come from acceptable data sources (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c07.pdf)
  • Be submitted at least once during the risk adjustment data reporting period
  • Be coded according to the ICD Clinical Modification Guidelines for Coding and Reporting

CMS currently conducts “comprehensive” Risk Adjustment Data Validation (RADV) audits to determine if diagnoses for risk scores submitted by Medicare Advantage plans are legitimate.  CMS reports that errors and omissions in the diagnosis data submitted by Medicare Advantage organizations account for the overall 9.5 percent rate of improper payments in Medicare Part C.  Up to now, CMS audits have not been “condition specific”; however, under the current proposal, in addition to the comprehensive audits, RACs would also conduct “condition-specific” RADV audits focusing on specific medical codes or health conditions, such as diabetes, that have high rates of payment errors.  The ultimate goal is to have all Medicare Advantage contracts subject to either a comprehensive or condition-specific audit for each payment year.

Comments on the Medicare Advantage RAC program must be received by 10:00 a.m. EST on February 1, 2016.  CMS said it will determine the next steps for procurement of a Part C RAC after reviewing all comments received by that date.

Read more posts at MiraMed

_______________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Global Services for MiraMed, a global healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

 

The post CMS for Medicare Advantage Risk Adjustment Update appeared first on REVENUE CYCLE NEWS.

 
TAGGED:Affordable Care ActCenter for Medicare and Medicaid ServicesCMS
Share This Article
Facebook Copy Link Print
Share

Stay Connected

1.5kFollowersLike
4.5kFollowersFollow
2.8kFollowersPin
136kSubscribersSubscribe

Latest News

5 Steps to a Promising Career as a Healthcare Administrator
5 Steps to a Promising Career as a Healthcare Administrator
Health
July 31, 2025
holistic dental
Holistic Dentist Services Are Natural and Safe
Dental health Specialties
July 28, 2025
botox certification
Help Improve People’s Skin Health Via Botox Certification
Skin Specialties
July 22, 2025
Telemedicine Apps
Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
Health
July 20, 2025

You Might also Like

The Problem with Medical Training: We Are Not Learning About the Causes of the Causes

May 23, 2012
small businesses and obamacare
BusinessFinanceHealth ReformPolicy & LawPublic Health

Small Businesses and the Not-So-Affordable Care Act

December 25, 2013
increased ER visits
BusinessFinanceHealth ReformHospital AdministrationPolicy & LawPublic Health

Is Our Medicaid System Vulnerable to Collapse in 2014?

January 6, 2014

People in High-Deductible Plans Short-Change Prevention

December 16, 2011
Subscribe
Subscribe to our newsletter to get our newest articles instantly!
Follow US
© 2008-2025 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Username or Email Address
Password

Lost your password?