The Department of Health & Human Services, on May 5, 2023, communicated to the Centers for Medicare & Medicaid Services (CMS) about instituting an “Interim Final Run” that relies on data submitted by the standard final risk adjustment data deadline for Payment Years (PY) 2023, 2024, and 2025.
The entirety of risk adjustment data, inclusive of both Risk Adjustment Processing System (RAPS) Data and Encounter Data System (EDS) Data, necessary for the stated risk score evaluations, needs to be submitted on the designated “Deadline for Submission of Risk adjustment Data.
Moreover, the nature of capitation and the risk adjustment payment method requires specific deadlines for data submission that correlate to ‘dates of service’ (DoS) and affect capitation payments.
Clicking on the above Downloadable link opens the table displaying timelines outlining the submission of risk adjustment data for calculating risk scores in payment years (PY) 2023, 2024, and 2025. It includes the initial, mid-year, and final risk score assessments, extending to the final PY 2024 risk adjustment data submission deadline. The table also presents relevant ‘dates of service’ (DoS) and risk adjustment data submission deadlines, listing future deadlines accordingly.
As such, the timelines mentioned in the table mandate accuracy in submissions from the outset, which is crucial for Health Plans and participating providers to make the most of this extended deadline.
Getting it right initially minimizes variability and maximizes payment optimization for Health Plans, especially during early submissions.
Below are some recommendations that Health Plans can consider to capitalize on this Opportunity fully.
- Streamline chart analysis with a robust chart retrieval solution.
- Ensure adequate coding and analyst resources for quality assurance.
- Target an engagement rate of 60%+ among the MA population.
- Ensure the primary solution provider is on schedule and adept in delivering results to other/secondary stakeholders.
- Schedule a review meeting for best practices and planning with solution providers.
- Opt for comprehensive risk adjustment solutions covering both retrospective and prospective ends.
In cases where in-house resources or expertise are lacking, which is typical for many organizations, seeking assistance from third-party consultants can prove effective.
Health Plans can take advantage of new-age technologies that can solve it all.
Alternatively, automated solutions are gaining traction, harnessing advanced technologies to help health plans efficiently and accurately identify, document, and validate conditions for which members received treatment. Some solutions leverage AI-supported technologies like Clinical NLP (Natural Language Processing) to optimize coding performance.
Should Health Plan as an organization decide to proceed with the delay, the above solutions can be considered to take advantage of this unique opportunity that suits Health Plans’ risk adjustment and quality needs.
Also, Engaging with industry peers, third-party consultants, or healthcare technology solution providers like RAAPID will enable Health Plans to fully leverage the advantages of this CMS risk adjustment submission deadline-2024.
Let’s collaborate to elevate your Risk Adjustment journey and seamlessly supplement your endeavors.