Let’s talk about the 2020 Part C Risk Adjustment Model

The 21st Century Cures Act of 2016 required CMS to augment the risk adjustment model to reflect the number of clinical conditions an individual member may have and to make additional adjustments as the number of conditions increases. For 2020, CMS is implementing an alternative payment condition count model that includes additional condition categories for pressure ulcers and dementia.

CMS began implementing the risk adjustment requirements in the 21st Century Cures Act in payment year (PY) 2019. CMS utilizes a risk adjustment model with additional factors for substance use disorder, mental health, and chronic kidney disease (CKD) diagnoses. It is important to remember the 21st Century Cures Act requires that CMS fully phase in the required changes to the risk adjustment model by 2022. The new phase of this model will begin in 2020. The blending of 50 percent of the risk adjustment model and 50 percent of the new risk adjustment model was first used for payment in 2017. This could create a rocky path for those who do not have a multi-faceted workflow and data process for risk-adjusting comprehensive clinical visits, EHRs, and claims files which are monitored, tracked and reconciled to return files.  If you want to read the details of the CMS final call letter, follow this link https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2020.pdf.