Health Risk Assessments (HRAs) are among the many鈥痶ools Medicare Advantage (MA)鈥痯lans use to support patients,鈥痠dentify chronic conditions early and prevent these conditions from becoming more serious.
Whether they occur in a beneficiary鈥檚 home or in a clinical office setting, HRAs offer an opportunity for the health plan and provider to obtain a complete evaluation of the patient鈥檚 physical, behavioral and mental health needs, medications, health risks and environmental factors that affect health.
The Centers for Medicare & Medicaid Services (CMS) has put robust systems in place to oversee diagnoses used for risk adjustment, including those identified during HRAs, and health plans and policymakers should continue working together to further improve this important tool that supports better health outcomes.
Unfortunately, a story published by The Wall Street Journal provides an incomplete portrayal of HRAs, including in-home HRAs that can reduce barriers to care for vulnerable seniors.
Here are some key facts for those seeking to better understand the use of HRAs in MA:
Diagnoses from HRAs are subject to stringent CMS requirements.
- CMS considers HRAs a best practice for all MA plans and their enrollees. In many cases, CMS requires MA plans to conduct HRAs.
- In-home HRAs are medical visits with clinicians, such as physicians and nurse practitioners, that occur in a patient鈥檚 home rather than the clinician鈥檚 office. To be eligible for risk adjustment payments, diagnoses identified through HRAs must be submitted through encounter data and meet the same risk adjustment eligibility requirements as diagnoses from in-office visits.
- All of these diagnoses are subject to CMS risk adjustment requirements, including that diagnosis codes are documented in the medical record and are documented as a result of a face-to-face visit with a clinician.
HRAs are a very small part of MA payment and CMS uses a range of tools to ensure payment accuracy in MA.
- Each year CMS receives diagnosis information from MA plans for all medical encounters, including HRAs.
- CMS has an audit program for risk adjustment payments that includes diagnoses identified during HRAs. As The Wall Street Journal story notes, CMS pointed out that 鈥渢he agency recently ramped up audits to verify diagnoses.鈥�
- Starting with 2024, CMS began to phase in new limits on risk adjustment payments, including those from HRAs. The Wall Street Journal鈥檚 story acknowledges that it was told by CMS that 鈥淸t]he agency also is eliminating some diagnoses from those that qualify for extra payments, including peripheral artery disease.鈥�
- CMS makes substantial cuts in risk adjustment payments to reflect more complete coding in MA. Those cuts 鈥� 5.9% annually 鈥� amounted to approximately $50 billion in reductions during the period covered by The Wall Street Journal鈥檚 story. This amount is far more than the total HRA-related payments for payment years 2019-2021.
- The payments resulting from diagnoses identified solely through HRAs accounted for less than 2% of total MA payments for the period (2019-2021) covered in The Wall Street Journal鈥檚 story. This is consistent with prior analyses by the Office of Inspector General (OIG) looking at diagnoses identified during HRAs.
- Medical loss ratio (MLR) rules ensure at least 85% of MA plan revenue is used to pay claims or for quality improvement programs. MA plans must return any excess funds to the government.
In-home HRAs can help reduce barriers to care and improve health outcomes.
- In-home HRAs 鈥渋dentify and meet the medical and nonmedical needs of vulnerable beneficiaries in their own homes and communities to impact health outcomes,鈥� a
by Manatt explains. 鈥淔or [vulnerable] populations, the [in-home HRA] can help remove barriers to care and improve access to preventive care services while fostering long-term care relationships, which are essential in ensuring equitable access to care and improving beneficiaries鈥� long-term outcomes.鈥�
- The Wall Street Journal story does not consider the clinical benefits that come from earlier diagnosing of diseases such as peripheral artery disease (PAD) that HRAs allow. PAD often goes undiagnosed and is associated with increased risk of coronary artery disease, heart attack and stroke. Early detection of PAD allows for effective primary and secondary prevention strategies to stop progression to critical limb ischemia and risk of amputation.
To learn more about HRAs, click here.