Risk Adjustment

CMS to Release Medicare Advantage Encounter Data

Sujata Bejaj, Episource’s Vice President of Product Development, provides her insights on what this data release could mean for health plans.

How can health plans leverage this CMS data release?

There are many potential uses for this data, but just to narrow the scope for our risk adjustment world:

  • For the first time health plans can create RA benchmarks that are MA correlated rather than FFS only.
  • They can assess where their member population is compared to others within the same providers, geographic location, age, disease categories etc (for 2015 at least)
  • If revenue is paid or the capitated indicators are released, the health plan can also assess the providers in their network and the payment arrangements (cap or FFS and what percentage of the medicare fee schedule is paid) for the same services.
  • Since this is 2015 only, as we get more data, we can come up with payment trends as well as disease trends.

How Episource leverages this data to better serve MAOs

  • We can provide region, age, specific bench marking and trending (over time) for comparative analysis to our clients.
  • Similar to what CMS does for ACA, health plans can understand if they are trending well below/above/same as their peers in the same Medicare Advantage marketplace.
  • We could pass the data through our epiAnalyst engine to build a repository of comparable member data by region. For example we could say in Harris County, TX the average RAF is X for a similar age and gender population.
  • This data would also be useful to benchmark Dx frequency by provider. By doing this health plans can determine whether providers are transmitting the same frequency of codes as they are to the rest of the population.

Episource provides guidance and assists health plans navigating regulatory changes to improve outcomes of their Medicare Advantage programs. If you are part of a Risk Adjustment team and would like an expert to provide recommendations, and help you identify opportunities for improvement, contact us by completing this form


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