FINAL PAYMENT NOTICE, RISK ADJUSTMENT, AND LETTER TO ISSUERS FOR 2021 Each year, the payment notification is published to execute several critical modifications that CMS plans to adopt in different domains such as exchanges, the Risk Adjustment plan, and regulatory reform for the next healthcare plan performance year.
The Centers for Medicare & Medicaid Services (CMS) has published a regulation establishing payment criteria and clauses for the risk adjustment program and cost-sharing principles. It addresses modifications to special registration periods, direct registration entities, administrative appeals procedures for healthcare insurance providers and non-federal governmental group private insurers, the Medical Loss Ratio (MLR) policy, proof of income by marketplaces, and other aspects. It also amends the law requiring eligible health coverage or their Pharmacy Benefit Managers (PBMs) to submit specific prescription medication data. Based on risk scores, the Risk Adjustment Model forecasts plan liabilities for an average insured person. All such risk scores are determined by the age, gender, and diagnosis of each insured person. Clinical diagnosis is also known as Hierarchical Condition Categories (HCCs). To deal with the cost disparities, the Risk Adjustment Solution employs distinct models for individuals, children, and newborns.The models for
child and adult combine individual's age, gender, and clinical diagnosis to generate an individual risk score. CMS has gradually added data for adults, including the registration duration variables and prescription medication categories to handle cost variations. NLP ENHANCES RISK ADJUSTMENT ACCURACY Healthcare plans can effectively and efficiently risk stratify their members using NLP-enabled coding systems, helping providers to focus and serve the at risk members. Also, concentrating on those with the most neglected diseases and the most significant number of claimed codes without evidence. This Natural Language Processing NLP-assisted risk classification adds tremendous value by allowing coders to prioritize the most critical members first. CMS HCC CODING RISK ADJUSTMENT METHOD: In the fiscal year 2021, CMS will continue to phase in the method that was adopted in 2020 and fulfills the legislative criteria of the 21st Century Cures Act. For the composite risk score assessment, the 2020 CMS HCC Coding method, formerly referred as the Alternative Payment Condition Count (APCC) model, will be employed along with the 2017 CMS HCC Coding model. Consequently, for 2021, healthcare organizations will generate risk scores according to Part I of the CY 2021 Advance Notice. Healthcare organizations will precisely measure 75 percent of the risk score assessed with the 2020 CMS HCC Coding model, utilizing accurate diagnosis from encounter statistics, RAPS inpatient logs, and FFS, with 25 percent calculated with the 2017 CMS HCC Coding model, employing diagnoses from RAPS and FFS.