With the implementation of the risk adjustment payment model, CMS has engaged in a transformation of the Medicare Advantage program designed to engage health plans in the management of Medicare beneficiaries health  services with an alignment of financial incentives which better matches care with resources. To adapt to  this strategic opportunity which this presents, health care provider need to understand the factors CMS uses to fund the health plan at the individual patient level and better organize their systems of care. CMS categorizes a patients disease burden by groups of ICD-10 codes and adds them up  and applies a hierarchy  of risk factors which together with demographic factors  constitute a risk score used to establish payment. The menu bar at right can lead you to tables which can be used to construct the risk score and training materials which can help physicians to comprehensively document their patient's disease burden. 

The payment model  rewards  a health plans careful  management of members with multiple chronic disease, when there is proper  documentation of their care.  Additional payments are made by CMS to health plans with effective outcomes  in the STARS program.  At the strategic level, a Medicare Advantage plan needs to look at who they market their services to, attract physicians who are effective in the treatment, management, and documentation  of patients with high disease burden, and design care management programs which address  the needs  of diabetics, patients with COPD,  CHF, heart disease and patients with chronic disease.  


Since CMS plans to implement a system to verify accurate payment and recover unsubstantiated payments, health plans need to address the risk of repayment  with a comprehensive approach to the management of compliance risk.  Such a plan at the strategic level requires the alignment of information systems technology beginning with an  electronic medical record integration strategy with  affiliated physicians, hospital and long term care facilities and home health care.  The billion dollar investment which has been made by Kaiser Permanente and its contracted Permenente Medical Groups provides a competitive advantage in the integration of medical information  for the management of   integrated care which is documented for audit and review by their internal compliance program and outside RADV CMS audits.  Similar efforts by Mayo clinic and other integrated delivery systems support the delivery of care under  the risk adjustment payment model.


Medicare compliance requires accurate documentation in medical charts. The same rules that already exist in fee for service for electronic medical record documentation apply in CMS audits of medical charts in a RADV audit. Quality improvement initiatives need to be reviewed and documented as part of a compliance  program. Cases are moving in federal court which will further define these requirements which CMS has been slow to provide explicit  guidance. The action in federal court in the MedXM whistleblower case will be important in case law for compliance purposes. If a health plan engages a firm to do in home assessments, then the electronic medical record documentation needs to be Medicare valid.  Valid user security is required to assure that the documentation can not be changed or copied over and have valid signatures. Just because  a plan has a contract for the services does not mean they have delegated the responsibility to have providers acting within their credentialed scope of practice. A  compliance plan should include internal audit of their contractors charts and corrective action documentation.  Review the compliance model under the Menu Bar, since the consequences of an ill-conceived risk adjustment program are substantial when placed under Inspector General review.  The  SCAN  Health Plan decision by the Department of Justice is also reviewed, and guidance CMS has made explicitly clear in the federal register for actions taken which game the Medicare program with retrospective review that does not correct  deficiencies in medial record documentations and retract diagnosis codes  used for  payment. 


The annual documentation of disease burden is a systematic approach to the treatment and documentation of chronic disease which is rewarded in the payment model. The  training materials are designed to support the education of physicians in this process. There are 60 slides which take  90 minutes to present. Initial assessment of new members by physicians or nurse practitioners under the direction of a physician where required by state law  and  trained in the HCC model can establish a more accurate baseline HCC score.  A care model which integrates the assessments into the delivery of care can also begin with a new member  welcome call and the scheduling of an annual physical with the patient's primary care physician.  


Care management of the patients  chronic disease by nurse  managers can  assure the annual documentation of treatment of chronic disease. The organization  of case management of the patients with  multiple chronic disease can start with risk stratification of high risk score members into care.


The information systems which support care processes are an essential area for redesign. The process redesign can include areas such as patient scheduling. The chief complaint entered by the scheduler of the patient visit can be redesigned to address  a patient's chronic disease.   High risk patients can be triaged for same day appointments to avoid an emergency room visit. Nursing home patients can be scheduled for chronic care. Review of  discharge summaries is  another area for process change. The physician office can be redesigned to include nurse case managers with chronic  care case loads. There are applications which provide cost accounting by HCC, diagnosis summaries and edits which prioritize patients for annual documentation of disease as well as highlight physicians who have adapted their practices to the risk adjustment model. These applications can track the documentation of disease burden in comparison to the previous years date of service to provide attention to the physicians which still need to know which patients require  documentation before the end of the calendar year.         


If your organization would like an assessment  of your  risk adjustment strategy or a review of its risk adjustment business processes  and care systems.  I can be reached at jswoben@aol.com.  I also can be contacted at the Medicare Risk adjustment linked in group. Please join at the link below. We have over two thousand  professionals from around the county, in many disciplines, who can bring their experience to a discussion topic.  You may also review the  wealth of information  from past discussions. Firms  also post jobs  opportunities and marketplace notices for products and services. Send me a note if you want to be listed as a service provider on this site or have a useful site.  

Best regards.

Jim Swoben MHCA  Long Beach CA  Tel:  562-439-5993 Email: jswoben@aol.com 

The CMS Medicare Managed care Manual chapter 7 is  in the folder below  as reference documentation for the Risk Adjustment model.