The Impact of COVID-19 on MA Payer Risk Scores
The delay of care due to the COVID-19 pandemic will undoubtedly impact the risk scores of beneficiaries in Medicare Advantage plans in the long term. Many of the services that have been postponed would have been the sources of diagnoses that MA plans use to document risk scores for their participants for the upcoming year.
The estimation of risk scores for the 2021 year will be based partly on diagnoses documented in 2020, and will be difficult given the unusual situation brought on by the COVID-19 epidemic. MA plans may be faced with a twofold setback that could lower risk scores due to the disruption in usual value-based care patterns, ending up with lower financial reimbursements from Medicare. First a decrease in visits resulting in reduced opportunity to document the patient’s disease burden and then a whipsaw effect resulting in higher healthcare costs later on due to the build up of delayed care.
A third impact of COVID-19 is that Medicare Advantage beneficiaries re-entering the healthcare system may have a condition that has gone undiagnosed or unmanaged, increasing the need for more serious intervention, posing a greater risk score than previously documented. At the same time, the intense pressure of the pandemic may take a toll on the provider workforce, creating new challenges for Medicare risk adjustment well after the volume of COVID-19 cases decreases.
A significant increase in chronic conditions like diabetes and COPD were seen for up to 18 months following the SARS epidemic in the early 2000s. Time will tell if an uptick of acute episodes not related to COVID-19, gone untreated, will pose challenges for the healthcare system moving forward.
The senior population’s unexpected utilization of remote care strategies during the COVID-19 pandemic has MA plans addressing how to provide better access to telehealth and other digital health technologies. But, while telehealth use has increased exponentially during the pandemic, more needs to be done to help with the adoption of audio-only telehealth visits to help minimize the risk of these beneficiaries’ conditions becoming uncontrolled. In time, as providers and beneficiaries become more comfortable with remote interactions, this may lead to remote care strategies occurring on a more frequent or even permanent basis. MA plans will need to consider the role that telehealth can play in service delivery in the future.
CMS recently started paying physicians for patient visits that take place via telephone and announced that MA plans will be permitted to use diagnoses recorded during telehealth visits under certain circumstances for risk adjustment coding. Risk scores are a critical part of plan payment and are also key in determining the level of rebates that can be applied to benefits. Plans must ensure that they are prepared to collect and submit data from telehealth services during the pandemic to document accurate risk scores for participants. In addition, plans will need to forecast the impact of 2020 remote care patterns on risk scores and identify ongoing significance.
To learn more about how ForeSee Medical can support you in managing the implications of COVID-19 on your business, request a demo of our HCC risk adjustment software and start getting the accurate reimbursements you deserve.
Blog by: The ForeSee Medical Team