Deep Dive Into the CMS Advance Notice

Amidst the many changes tucked away in the Centers for Medicare & Medicaid Services (CMS) 2024 Advance Notice were significant ramifications for risk adjustment, coding and quality regulations. The new compliance and quality standards presented by CMS fundamentally transform how Medicare Advantage plans develop risk adjustment and Star Ratings strategies to improve plan performance.

Healthmine and RISE Health partnered together to analyze and address the most pivotal changes coming out of the 2024 Advance Notice and the Risk Adjustment Data Validation (RADV) Final Rule during an insightful webinar. Speakers included:

• Melissa Smith, Executive Vice President, Consulting & Professional Services
• Kimberly Swanson, Senior Vice President, Consulting & Professional Services
• John Willis, Vice President, Consulting & Professional Services
• Ben Poehling, Senior Advisor, Consulting & Professional Services
• Dr. Shannon Decker, M. Ed., MBA, PhD., Principal, VBC One
• Ana Handshuh, Principal, CAT5 Strategies

Moderated by Kent Holdcroft, Chief Growth Officer, our presenters tackled two key areas of concern: risk adjustment and quality measures. Watch the on-demand webinar and download the presentation slides to get the insights you need to evolve your Star Ratings and coding tactics to the new normal for compliance and quality.

Implications of the RADV Final Rule

Through the Medicare Advantage RADV program, CMS is required by federal law to audit risk adjustment payments to determine if the department overpaid health plans. For many plans, the looming question was not if CMS will perform audits, but when. According to the RADV Final Rule, Medicare Advantage plans can expect CMS to begin extrapolating risk adjustment audits beginning with payment year 2018 and will conduct these audits in 2025.

In his analysis, Ben Poehling tackled several questions surrounding the implications of the RADV Final Rule on Medicare Advantage plans:

• Has CMS determined a specific audit methodology?
• Will audits apply at the member level or contract level?
• Does the RADV Final Rule apply to the Office of Inspector General audits as well as CMS audits?
• How will providers and vendors be impacted by RADV audits and clawback clauses?
• How can plans structure bids to protect against potential audits?
• What can plans do now to address RADV audits?

Proposed Payment Rates and Coding Changes

The expected average change in revenue for Medicare Advantage plans caught a lot of attention when it was first showcased in the 2024 Advance Notice. While the 2022 and 2023 Final Rate Announcement saw a seismic shift from 4.08% to 8.5% in revenue increases respectively, the 2024 Advance Notice proposes that payment rates will only increase by 1.03% on average.

Poehler noted that there are several factors that will be considered when determining a plan’s revenue, including contracts, county rate calculations and Star Ratings performance, and that the final rate will vary. To help plans understand the context of the proposed payment rates, Poehler broke down the potential changes coming to the risk adjustment model, risk adjustment scores and removal of several HCC diagnostic codes.

Dr. Decker provided additional insights into these risk adjustment changes at a provider level and shared best practices for adapting to the new coding methodology. Risk adjustment analytics, population health management, preventive care and disease management interventions, and provider education are just a few areas plans can focus attention to evolve strategies alongside CMS’s proposed changes.

Key Star Ratings Proposals

Alongside the updates CMS is proposing for finances, coding and compliance standards, Medicare Advantage plans must also adapt to many long-awaited quality and operational changes. Healthmine’s Expert Advisory Team worked with Ana Handshuh to outline the key regulations plans should account for in their Stars work plans:

• The standardization of the Tukey outlier deletion methodology for determining cut points and the resounding impact on Star Ratings calculations.
• CMS’ proposal to limit the hold harmless provision to 5 Star plans when determining the benefits of the Quality Improvement measures, potentially leading to plans losing their 4.0 or 4.5 Star Ratings.
• The urgency of the health equity timeline with two major regulations ready to take affect in measurement year 2024: the Health Equity Index and the new Social Need Screening and Intervention (SNS-E) Healthcare Effectiveness Data and Information Set (HEDIS®) measure.
• The importance of adopting a health risk assessment that is certified by the National Committee for Quality Assurance (NCQA) and the variety of data sources plans can use to address the SNS-E screening requirements. 
• How plans can use their 2024 bid enhancements to support strategies to address these new regulations.

What Plans Should Do Next

Before hopping into questions with the live audience, our presenters outlined their strategies for getting ahead of CMS’ proposed changes:

• Capture codified changes into every report, dashboard and analytical model to ensure all stakeholders are aware of what’s to come.
• Educate and prepare team members with the latest regulatory standards to ensure they can perform their duties effectively.
• Clear calendars of unnecessary meetings to enable teams to quickly action strategies to meet CMS’ proposed measure timelines.
• Partner with IT and analytics teams to advance interoperability throughout the entire organization.
• Address upcoming Part D measures, such as Concurrent Use of Opioids and Benzodiazepines, and health outcome survey measures related to mental health in 2023 to safeguard future performance.
• Get familiar with change management and prepare teams to adapt rapidly to new programs, regulations and compliance standards.
• Use analytical models and current data to show stakeholders how the regulations will impact Star Ratings and operational performance today.

Access a wide range of insights and expertise on risk adjustment, coding and quality performance and health equity by filling out the form and watching the full on-demand webinar.