APMA News - July/August 2021 - 21

Reimbursement
By the APMA Health Policy and Practice Committee
Medicare Advantage Plan Updates
APMA continues to receive reports from members across
the country about chart reviews by Medicare Advantage
(MA) plans or their subcontractors. While MA plans may
request records for a variety of reasons, such as to ensure
appropriate payment or to look for evidence of fraud and
abuse, the requests are often related to identifying or confirming
diagnoses. With dual pressures on MA plans to both
capture all diagnoses and ensure diagnosis codes submitted
to CMS are supported by the relevant medical records, it is
unlikely such reviews will subside in the near future.
Beginning in 2007, MA plan payment from CMS became
100-percent risk adjusted. The risk adjustment is based on
hierarchical condition categories (HCCs). CMS publishes a
list of ICD-10 codes that make up the HCCs. Thus, the
more of these ICD-10 codes a plan can capture, the more
accurately the payment level reflects the health risks of the
population enrolled in the plan.
From the beginning, CMS recognized that MA plans
would need to rely on the providers who furnish services to
their members in order to meet their obligation to submit
data to CMS. The MA regulations explicitly state, " MA organizations
must obtain the risk adjustment data required by
CMS from the provider, supplier, physician, or other
practitioner that furnished the services. " i
The regulations
further stipulate that " MA organizations may include in
their contracts with providers, suppliers, physicians, and
other practitioners, provisions that require submission of
complete and accurate risk adjustment data as required by
CMS. These provisions may include financial penalties for
failure to submit complete data. " ii
Few (or no) plans have
chosen to impose such penalties, instead opting for a more
cooperative approach.
MA plans found, however, that they were receiving incomplete
data from their contracted providers through
claims. They found that physicians frequently submitted
only the codes necessary to get paid, focusing more on CPT
codes than diagnosis codes. Moreover, for MA plan members
with stable chronic conditions, codes get dropped from
year to year. MA plans need to have the chronic condition
diagnosis entered into the medical record as a result of a
face-to-face visit at least once a year in order to submit the
code for risk adjustment purposes.
Therefore, many MA plans opt for chart reviews to ensure
all the relevant diagnostic data has been captured. To submit
a diagnosis to CMS, it must be documented in a medical
Continued on page 22
APMA News July/August 2021 21

APMA News - July/August 2021

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Contents
APMA News - July/August 2021 - Cover1
APMA News - July/August 2021 - Cover2
APMA News - July/August 2021 - 3
APMA News - July/August 2021 - 4
APMA News - July/August 2021 - 5
APMA News - July/August 2021 - 6
APMA News - July/August 2021 - 7
APMA News - July/August 2021 - Contents
APMA News - July/August 2021 - 9
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APMA News - July/August 2021 - Cover3
APMA News - July/August 2021 - Cover4
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