Best Practices to Manage the CMS Risk Adjustment Timetable

Best Practices to Manage the CMS Risk Adjustment Timetable


The Centers for Medicare and Medicaid Services (CMS) recalibrates Medicare Risk Adjustment (MRA) scores for health plans’ Medicare Advantage members three times each year.

Paying close attention to deadlines and changes in regulations can help your plan avoid costly adjustments as  CMS calculates the risk scores that determine a Medicare Advantage member’s premium based on the data that you submit through both Risk Adjustment Payment System (RAPS) and Encounter Data Processing System (EDPS).

Allowing adequate time for medical record retrieval, abstraction and validation is crucial in substantiating diagnoses codes that underpin the Hierarchical Condition Categories (HCC) that CMS uses to assess risk and adjust payments. Claims data alone is not sufficient to assure the completeness and accuracy of each member’s risk profile.  Data must be based on face-to-face visits with care providers and submitted before one of the three deadlines for a payment year, depending on the date of service, which could be within three months of the data submission deadline.

Accuracy is also vital since risk scores are increasingly based on encounter data as CMS transitions from its Risk Adjustment Process System (RAPS) to its Encounter Data Processing System (EDPS) as it seeks to base risk adjustment payments on more detailed records. You must ensure that your encounter data is accurate in order to preserve, or perhaps increase, the amount of your monthly risk adjustment payment.

Submit complete, accurate and timely data by following these best practices for managing the CMS Risk Adjustment timetable.

1) Beware of regulatory changes.

CMS regularly changes its risk adjustment model and risk adjustment factors. Check the announcements of methodological changes on its website.

Regulators will typically announce an early preview for an upcoming payment year more than 12 months prior to its beginning.  For example, the early preview for rate year 2017 was issued in December 2015.

An advance notice then follows early in the next calendar year (i.e. February 2016 for 2017) and a final announcement is made in April of the preceding year. The Calendar Year 2017 CMS announcement was made in February 2016.

Review each announcement as it comes out for any possible or upcoming methodological changes so that you can plan accordingly.

2) Encourage early intervention.

Educate providers on the importance of properly documenting a member’s health and monitoring it throughout the year. A wellness checkup at the start of the payment year can help you substantiate prior diagnoses with additional documentation.

New diagnoses that could impact the risk score could arise as well. Instructing a provider in how to inquire about changes in a member’s health and document them properly will help you and the provider preserve revenue.

3) Follow up regularly.

MA members who see a provider once a year may not get the care they need to maintain their health. Nor will your plan necessarily get the documentation that it needs to substantiate diagnoses.

Inform members that it is important for them to see their physician throughout the year. Such consistency is particularly important for members who have been diagnosed with conditions. Retrieving and abstracting records from these ongoing visits will help you submit complete, accurate and timely data prior to each deadline in the CMS risk adjustment timetable.

4) Don’t wait.

The deadline for CMS risk adjustment data for the initial risk score run for payment year 2017 is Sept. 9, 2016, so confirming accuracy for data associated with dates of service between July 1, 2015 and June 30, 2016 will be important.

Given the quick turnaround that the September deadline presents for June dates of service, don’t wait to retrieve records from visits made prior in 2016 or as far back as mid-2015. Retrieve and process records throughout the year  ratherthan waiting for the year to end.

Staying ahead of changes in regulations and working well in advance of data submission deadlines will help you maintain, or perhaps improve, risk adjustment scores by submitting complete, accurate and timely data. Follow these CMS risk adjustment best practices to drive complete, accurate and timely revenue generation.


via Best Practices to Manage the CMS Risk Adjustment Timetable


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