If you read the memo and muttered, "uh-oh" under your breath, you might be thinking that your plan/organization owes CMS some money, and soon. If you haven't read this memo, "uh-oh" would be an understatement.
On March 3, Cheri Rice, CMS' Director of Medicare Plan Payment Group, released a memo notifying all Medicare Advantage Organizations, PACE Organizations, and certain Demonstrations of its intent to rerun risk scores during the calendar year 2015.
The memo was brief and a bit vague, but the impact to health plans and providers could not be clearer. CMS will be rerunning risk score data and the corresponding payments made to plans dating back to 2008 Dates of Service (DOS), payment year 2009. Additionally, the memo anticipates that plans will clean up their data by submitting deletes. This could raise the specter of false claims if a plan fails to submit deletes when they knew, or should have known, of unsubstantiated risk adjustment submissions. This could get ugly, and fast.
The table below was included in the memo and outlines the DOS and payment years that CMS intends to rerun, assess, and then start collecting:
Do you know if your plan is at risk for receiving a letter from CMS requesting "money back?"
Better yet, do you find yourself asking:
What is your level of exposure and how much money might you owe CMS depending on their findings?
Do you know how many risk-adjustable diagnoses will be swept away when CMS reruns the data, and do you have the ability and infrastructure to conduct that analysis?
What is the impact of the overpayment recovery effort on my provider contracts, relationships, and reimbursement?
How will this effort impact my medical management, quality, and affordability strategies? Is this on my radar for our ICD-10 preparedness plan?
Daniel Weinrieb is senior vice president of risk adjustment at the Gorman Health Group, where this post first appeared.