MAPD Risk Adjustment Score

[somarco]

Do risk adjustment scores for an individual change from year to year based on collected data or are they fixed "for life"?

If someone who joins an MAPD plan has a risk adjustment score of say 1.5 based on medical data, but later on their health improves, is their risk score lowered to reflect improved health?

 

[axeman462]

Do risk adjustment scores for an individual change from year to year based on collected data or are they fixed "for life"?

If someone who joins an MAPD plan has a risk adjustment score of say 1.5 based on medical data, but later on their health improves, is their risk score lowered to reflect improved health?

they are recalculated annually

 

[somarco]

@axeman462 thank you!

 

[Fisher]

I have never heard of an MAPD risk adjustment score.

 

[MedicareWAA]

Do risk adjustment scores for an individual change from year to year based on collected data or are they fixed "for life"?

If someone who joins an MAPD plan has a risk adjustment score of say 1.5 based on medical data, but later on their health improves, is their risk score lowered to reflect improved health?

Beneficiaries are re-scored at least annually, and the scores are based on actual clinical encounters. Not surveys.

The encounter codes are based on ICD, not CPT. Every ICD code has a very specific clinical definition. You can’t just say someone has diabetes. Poorly managed diabetes = A1C score is X and blood sugar is Y and Test A is negative and the patient has comorbidity X or Y but not Z. The clinical record must contain proof that the ICD code meets its definition.

The ICD codes feed into a system called HCC. Certain combinations of ICDs map to certain HCCs that, in turn, produce a risk score. Some ICDs have no impact on scores, and some are well understood to produce thousands of extra dollars per member per year. ICD combinations matter, too. A certain type of depression in people age abc+ was one of those codes. The government just shut that one down.

Codes expire. If someone was coded as a blind paraplegic with bad diabetes, and that person goes 12 months without being re-coded (which requires a clinical encounter to re-establish the data to support the ICDs), the government assumes they are no longer paralyzed and no longer have diabetes and suddenly figured out how to see well. Their risk score goes back to 1.0.

This is why carriers like to send nurses to members’ houses, incentivize them to get an annual physical, and so forth. It’s why every carrier has hundreds of people who study claims data to find coding opportunities. No matter how the carrier spins it, these things are mostly about harvesting and protecting the codes that map to the highest value HCCs.

Risk scores are not updated immediately. Some very expensive conditions are money losers just because the member will die before their risk score has time to reset. Stage 4 pancreatic cancer, etc.

Carriers love members with chronic diseases that can be managed. Think cardiovascular stuff, diabetes, COPD. The scores can be super high but the costs can still be managed with outreach and engagement.

People like to say an Advantage member produces about $12,000 of annual revenue from CMS. Lost in that number is that there are plenty of members producing $30,000 or $40,000 of revenue each year.