In the intricate world of Value based care, where precision and accuracy can make all the difference, one critical aspect often overlooked is risk adjustment data submission. This process, essential for both providers and payers, ensures that healthcare organizations are appropriately reimbursed for the care they provide, while also reflecting the true health status of their patient population.
Importance of CMS Risk Adjustment Data Submission
A 2019 OIG report released in December 2019 estimated that diagnoses sourced from retrospective chart reviews accounted for $6.7 billion in payments to MA plans in 2017.
Furthermore, Under the final rule, significant financial stakes are evident, with CMS projecting $4.7 billion in additional recoveries from MAOs between 2023 and 2032.
Accurate Risk Adjustment Data Submission in 2025
Let’s probe the key aspects and challenges of risk adjustment data submission.
2025-2026 CMS RA Submission Deadlines
Never Miss a Critical CMS Risk Adjustment Deadline
Accurate Documentation – Without it, CMS Submissions are Inconsequential
Retrospective risk adjustment ensures that healthcare organizations receive accurate reimbursements by reviewing past claims for provided services. After care delivery and claim submission, retrospective coding reviews often identify HCC codes that were either unreported despite being supported by medical records or inaccurately submitted without meeting documentation criteria. These assessments commonly reveal recurring clinical documentation issues, prompting the need to rectify and resend the accurate HCC codes to the payer.
Improper Documentation can be a challenge for Risk Adjustment Data Submission:
- Incomplete documentation causes inaccurate coding: Missing details lead to errors, impacting reimbursements, distorting risk assessment, and potentially increasing fraud risks.
- Comprehensive patient data is not always easy to Collate : The existence of disparate sources to Capture the holistic health profile of patients with all the nitty gritty details, plus improper unified workflows & non-interoperability factors, can become an issue with healthcare organizations in gathering data, which can hamper clinical documentation required for Risk Adjustment Data Submission.
- Limitations of claims and clinical data for risk assessment: Claims miss lifestyle data, and clinical records may lack comprehensive health insights, impacting risk assessment accuracy.
- Diverse data formats : Data in varying formats, like handwritten physician notes or improperly scanned patient Billing, lab, and pharmacy records, must be processed to extract relevant data to suffice clinical documentation.
- Challenges of integrating diverse data sources: A complex, time-consuming process, costly to manage, and requires standardization and advanced analytics to gather meaningful insights for CDI purpose.
- Standardization and advanced analytics for data utilization: Crucial for extracting insights, calculating accurate risk scores, facilitating fair reimbursements, and fraud prevention.
- Improper documentation may not serve Complaint-ROI: Inadequate documentation addresses missed diagnosis codes or potential down-coding, affecting revenue and risk-adjusted savings analysis. It disrupts clinical workflow, hindering code recapture and condition assessment. Additionally, it delays healthcare networks in justifying admission and treatment. Deficient patient documentation can misrepresent the severity of medical conditions and inaccurately assess their risk, leading to suboptimal financial outcomes.
Thus Thorough documentation plays a vital role in accurate HCC coding, ensuring timely Risk Adjustment data submission to CMS. It also reflects members’ health accurately, reducing fraud risks and achieving compliant ROI.
Factors Affecting CMS Data Submission
Medical Record
- Patient Identification: Each page should bear the patient’s name, date of service (DOS), and another identifier such as date of birth (DOB).
- Chief Complaint (CC): A detailed description of why the patient seeks care, not just a generic “follow-up”.
- Examination Report: Detailed findings from the patient history, highlighting any positive or chronic conditions affecting treatment.
- Medical Decision-Making: A comprehensive assessment of diagnoses, including chronic conditions, and a clear plan for treatment & prescription.
- Authentication: Handwritten or electronic signatures and credentials to validate the provider’s involvement.
Demographic Factors
Beyond diagnoses, demographic factors like age, sex, socioeconomic status, and Medicare beneficiary eligibility are crucial in determining risk scores. These factors provide a more holistic view of a patient’s health and influence reimbursement rates accordingly. During the payment year, CMS considers the enrollee factor to support a risk score as per the effective dates of coverage and change of coverage along with continuation or discontinuation of enrollment benefits.
Chronic Conditions
Chronic conditions are not a one-time affair; they require ongoing attention and documentation. Providers must annually recapture chronic conditions, ensuring they are reported accurately during each encounter. Additionally, conditions documented by other healthcare professionals should not be overlooked.
Encounter Data
Encounter data, comprising claims data and authenticated diagnoses holds immense value in risk adjustment. It serves as authentication for submitted diagnoses and maximizes code capture, ensuring accurate reimbursement.
Timely Filing and Audits
Timely filing of claims is paramount to avoid potential financial penalties. CMS scrutinizes claims filed beyond specified timelines, which could trigger audits and subsequent financial repercussions. All dates of service must be signed (with credentials) and dated by the physician (provider) or an appropriate extender (for example, a non-physician practitioner such as a PA, NP, CNS, etc.)
Adapting to Regulatory Changes
CMS constantly updates its risk adjustment models to reflect evolving healthcare practices. From the earlier ICD-9-CM V24 Model to a revamped HCC Model aimed at aligning diagnoses with the ICD-10-CM (V28) classification system. While these changes may seem daunting, they ultimately promote consistency and accuracy in risk adjustment.
Two of the most significant changes are the drive toward value-based care and the introduction of the V28 Hierarchical Condition Category model. Together, these two developments have created urgency for health Medicare Advantage organizations to deliver better, more cohesive experiences to patients. CMS has also decided to eliminate the FFS adjuster that has been used to offset the error rate in the data. With this change, organizations will need to provide more documentation to CMS.
Official CMS RADV Audit Checklist
Prepare & Pass Your Next CMS RADV Audit
Ensuring Accuracy
Whether you’re a healthcare provider or part of a payer organization, understanding coding nuances and adhering to best practices is crucial. By accurately documenting encounters and submitting claims promptly, you contribute to a smoother, more efficient healthcare ecosystem.
In essence, risk adjustment data submission is the cornerstone of fair reimbursement and accurate portrayal of patient health. By adhering to documentation standards, embracing demographic factors, and staying abreast of CMS updates, healthcare stakeholders can navigate this complex landscape with confidence and integrity.
Inefficient Workflows & Manual Processes Affect Data Submission
- Inadequate Workflows: Poor Clinical workflows are not easily customizable for error rectification, leading to delays and inaccurate submissions.
- Data Volume Overwhelm: Government program data demands are immense; inefficient processes can impede compliance and cause revenue loss.
- Manual processing Challenges: Manual processing hampers error identification and lacks critical insight pertaining to coding and documentation areas.
- Workforce Reallocation: Redirecting in-house IT resources from manual tasks to strategic projects is not advisable.
Regulatory Changes Affecting CMS Data Submission
Compliant submission entails documenting all current conditions accurately, excluding those absent. Accuracy requires matching the code acuity precisely to physician descriptions, excluding unrelated conditions.
Significant regulatory changes have recently impacted Medicare Advantage Organizations (MAOs) compliance requirements. The Centers for Medicare and Medicaid Services (CMS) introduced extensive modifications to audit protocols and the underlying risk adjustment model. These changes stemmed from uncertainties surrounding the reliability of specific condition codes as indicators of future costs. Also, long-pending industry concerns about underpayments and overpayments attributed to outdated risk adjustment approaches acted as change agents.
Prime regulatory changes affecting Risk Adjustment Data Submission in terms of time & managerial resources
- Notable regulatory changes affecting MAOs: CMS implements sweeping changes to audit processes and risk adjustment models amid lawsuits and OIG reports due to concerns over coding credibility and overpayments.
- RADV Final Rule and increased audits: CMS finalizes the rule, allowing extrapolation of RADV audit findings. This will lead to more frequent audits and significant fines for MAOs.
- Changes in diagnosis coding under Final Rate Notice: CMS shifts to ICD-10 and removes over 2,000 codes from the HCC model, adopting a new risk adjustment model phased in over three years.
- Introduction of bipartisan Senate bill: Bill seeks to exclude chart review and health risk assessment diagnoses from risk score calculations, reflecting a shift away from legacy models.
- Opportunity for MAOs to review risk adjustment solutions: Under the Final Rate Notice, the phased-in approach allows MAOs to reassess risk adjustment strategies for compliance and effectiveness in the new regulatory landscape.
Can outsourcing solve your risk adjustment data submission issues?
The following scenarios illustrate how outsourcing risk adjustment services can help ensure precise and timely CMS data submission This lets you concentrate on your risk adjustment objectives, ensure compliance, and optimize revenue.
- Scenario 1:
Consistent Quality and Coding Precision: Flexibility is crucial for maintaining consistent quality and accuracy in medical coding services, regardless of workload fluctuations. Unlike in-house coding departments with limited staffing, outsourcing provides access to a large, adaptable team of skilled experts. - Scenario 2:
The Need to Prioritize Core Activities: Utilizing time and resources for in-house medical coding can detract from core activities. The bandwidth needed for training and managing coding staff may lead to project delays. Outsourcing coding operations reallocates resources, allowing core activities like patient management and care quality to proceed without interruption. - Scenario 3:
Looking for Qualified Medical Coders: A shortage of qualified medical coders, worsened by the shift to ICD-10 and workforce turnover, poses challenges in finding experienced coders. Outsourcing is all about an On-demand quality workforce. - Scenario 4:
Facing challenges in Internal Technology Development: Management prioritizes investing in core areas like enhancing patient care over developing in-house technologies, which require technical expertise and specialized maintenance. Outsourcing tech needs may be a more practical solution.
Key Vendor Selection Criteria to Take Care of CMS Data Submission
Choosing a vendor with a profound grasp of risk adjustment methods is vital, particularly for a comprehensive solution covering the entire process.
Key Risk Adjustment Vendor Selection Criteria Checklist:
Expertise across risk adjustment processes:
What expertise does the risk adjustment vendor offer across different business lines? Look for proven legacy, track record, and adaptability.
Experience and track record:
Seek vendors with a successful history in healthcare risk adjustment. Experience with payers, providers, or government agencies indicates expertise and reliability.
Coding competency of vendor:
It goes without saying that any coding technology that a health organization adopts should make it easy for coders to review charts and enter proper HCC codes. But there’s more to the chart review experience than simply entering new HCCs.
Some other factors to consider include:
- Adds & Deletes: Is the vendor capable of conducting chart reviews using MEAT framework for both additions (supported HCCs) and deletions (unsupported HCCs)? Examining both aspects is crucial in today’s meticulously regulated environment.
- Trace-mapping: Does the vendor offer a transparent audit trail for coding decisions? Is it clear which team member handled each chart, assisting with corrective measures if necessary?
- Performance Monitoring: Does the platform offer metrics regarding coder accuracy and productivity to aid in making informed decisions regarding education and staffing?
Chase List Prioritization:
Review vendor’s skill to prioritize high-risk conditions, conduct chart reviews, ensure accurate coding, and address incomplete documentation promptly.
Chart Retrieval:
Assess the vendor’s chart retrieval process, crucial for securing accurate medical records and provider documentation for precise patient diagnosis coding.
Insights and Analytics:
What value do coded HCCs offer? Which chronic conditions prevail among members? Identify providers with inaccurately coded HCCs. Your tech vendor should help address these program queries.
Cost-effectiveness and ROI:
Assess the vendor’s solution cost against potential ROI gains, considering enhanced risk scores, revenue, efficiency, and regulatory compliance. Ensure AI-based audit technology for RADV/OIG compliance.
Accuracy and transparency:
Evaluate the vendor’s risk adjustment data accuracy and quality assurance methods, including validating data extraction and employing OCR-readable clinical charts for streamlined processes. Ensure evidence-based coding predictions and comprehensive audits.
Smart process execution and on-time deliverables:
Assess the vendor’s smart analytics and AI to identify high-risk patient populations. Ensure thorough testing of automated audit reviews and HCC coding. These solutions should have effectively integrated industry-standard knowledge graph-powered clinical NLP technology.
Interoperability and Chart (Data Exchange) Processing:
Verify vendor solution aligns with interoperability standards, facilitating seamless data exchange with EHRs and stakeholders via industry-standard formats, APIs, and integration protocols.
Integration with Clinical Data Systems:
Does the vendor comprehend your workflow? Ensure their solution integrates seamlessly with clinical systems and EHRs to capture relevant data.
Support Services:
Does your team receive training from the vendor as part of payer education? Evaluate vendor training for users’ tech proficiency and process orientation. Tracking performance metrics and KPIs ensures program success and compliance with CMS requirements.
Privacy and Security Management:
Assess the vendor’s adherence to CMS, HIPAA, and industry standards for data security. Inquire about user permissions and access controls, including HIPAA/HITRUST/SOC2 compliance.
Scalability and Flexibility:
Evaluate the vendor’s solution for scalability, adaptability to changing regulations, and collaboration with third-party providers for specialized solutions, ensuring seamless business continuity.
Receptiveness to changing project dynamics:
Assess the vendor’s responsiveness to project changes, including team onboarding and data gathering, to ensure timely execution.
Planning for Risk Adjustment Data Submission Success in 2025
Although the CMS processing period for risk-adjusted payments spans a calendar year, risk adjustment activities can extend up to 2¼ years beyond the date of service. Understanding the timing of these activities is crucial for accurate data reporting, removal of any inappropriate data, and readiness for RADV if chosen.
Moreover, the subsequent phase following data submission, which encompasses managing RAPS and EDPS response reports, can be lengthy due to diverse formats, potentially originating from sources like CMS, providers, or health plan submissions. Consequently, the entire cycle of risk adjustment data submission entails numerous procedures and timelines, highlighting the necessity for advance planning and preparedness.
Planning and Preparedness – Risk Adjustment Data Submission
- Establish a centralized document repository: A centralized document repository is the cornerstone for optimization; it ensures accessibility to medical records, metadata aids retrieval, OCR for paper records, and analytics utilize data for risk adjustment.
- Invest in advanced automation and intelligent tools: Automate processes like EDPS and RAPS submissions, coding, and analysis; some are available as a service, enhancing efficiency and cost-effectiveness.
- Develop forward-looking capabilities: Anticipate risk adjustment scores, forecast revenues, predict population health trends, identify high utilizers, and address Social Determinants of Health.
- Establish a RADV audit action plan: Detail retrieval and reporting of data, streamline tasks with a single data repository and automation, educate internal associates, and develop an implementation plan.
How Health Plans can leverage CMS Risk Ajustment Deadline Extension
The Department of Health & Human Services, on May 5, 2023, & May 1, 2024 communicated to the Centers for Medicare & Medicaid Services (CMS) about instituting an “Interim Final Run” that relies on data submitted by the standard final risk adjustment data deadline for Payment Years (PY) 2024, 2025, and 2026.
The entirety of risk adjustment data, inclusive of both Risk Adjustment Processing System (RAPS) Data and Encounter Data System (EDS) Data, necessary for the stated risk score evaluations, needs to be submitted on the designated “Deadline for Submission of Risk adjustment Data.
Moreover, the nature of capitation and the risk adjustment payment method requires specific deadlines for data submission that correlate to ‘dates of service’ (DoS) and affect capitation payments.
Understanding CMS Risk Adjustment Deadlines: Key Dates and Processes
The submission of risk adjustment data is critical for accurate payments under CMS guidelines, impacting the financial integrity of Medicare Advantage plans. Each payment year relies on data from a 12-month period before the payment year, with a potential 6-month data lag as determined by CMS. Notably, there are two main deadlines: the first Friday in September for data through June 30, and the first Friday in March for data through December 31 of the prior year.
Once the payment year concludes, CMS recalculates risk factors, adjusting payments as necessary. This includes a reconciliation period allowing data submissions beyond the March deadline until the final submission date, typically announced by CMS.
Importantly, after this final deadline, organizations can submit data to correct overpayments but cannot add new diagnoses for additional payments.
Retrospective Payment Reconciliation: When it comes to Risk Adjustment data submission, the sequential “runs” play a crucial role in refining the accuracy of risk scores and financial adjustments based on an evolving set of data from past dates of service (DOS). Retrospective reviews allow health plans to improve the precision of payments, facilitating the capture of changes in enrollee health status more comprehensively over time.
The goal of the retrospective review is to ensure comprehensive coding accuracy and submit data that align with CMS norms & standards as per the established risk adjustment models, such as the CMS-HCC model for Medicare Advantage plans.
Here’s a how retrospective review process makes for a healthy Risk Adjustment Data submission practice.
Data Collection and Chart Review: Retrospective risk adjustment begins with the collection of past patient data and medical records. Retrospective chart reviews allow coders to assess medical documentation for any missed diagnoses or conditions relevant to the risk adjustment model. During chart reviews, coding specialists examine each patient’s historical data to validate diagnosis codes or add any missed ones.
Submission Compliance: Once coding and documentation accuracy are confirmed, the corrected or completed data is submitted to the Centers for Medicare & Medicaid Services (CMS) or other relevant authorities. Compliance with CMS guidelines is essential, as inaccurate data can lead to audits, penalties, and payment discrepancies.
Impact on Financial and Quality Measures: Accurate retrospective data submission allows health plans to adjust payment calculations based on the risk level of the populations they serve. It also contributes to more precise quality and outcome metrics, enabling better resource allocation and care planning for high-risk patients.
Clicking on the above Downloadable link opens the table displaying timelines outlining the submission of risk adjustment data for calculating risk scores in payment years (PY) 2024, 2025, and 2026. It includes the initial, mid-year, and final risk score assessments, extending to the final PY 2024 risk adjustment data submission deadline. The table also presents relevant ‘dates of service’ (DoS) and risk adjustment data submission deadlines, listing future deadlines accordingly.
As such, the timelines mentioned in the table mandate accuracy in submissions from the outset, which is crucial for Health Plans and participating providers to make the most of this extended deadline.
Getting it right initially minimizes variability and maximizes payment optimization for Health Plans, especially during early submissions.
Below are some recommendations that Health Plans can consider to capitalize on this Opportunity fully
- Streamline chart analysis with a robust chart retrieval solution.
- Ensure adequate coding and analyst resources for quality assurance.
- Target an engagement rate of 60%+ among the MA population.
- Ensure the primary solution provider is on schedule and adept in delivering results to other/secondary stakeholders.
- Schedule a review meeting for best practices and planning with solution providers.
- Opt for comprehensive risk adjustment solutions covering both retrospective and prospective ends.
In cases where in-house resources or expertise are lacking, which is typical for many organizations, seeking assistance from third-party consultants can prove effective.
Health Plans can take advantage of new-age technologies that can solve it all
Alternatively, automated solutions are gaining traction, harnessing advanced technologies to help health plans efficiently and accurately identify, document, and validate conditions for which members received treatment. Some solutions leverage AI-supported technologies like Clinical NLP (Natural Language Processing) to optimize coding performance.
Should Health Plan as an organization decide to proceed with the delay, the above solutions can be considered to take advantage of this unique opportunity that suits Health Plans’ risk adjustment and quality needs.
Also, Engaging with industry peers, third-party consultants, or healthcare technology solution providers like RAAPID will enable Health Plans to fully leverage the advantages of this CMS risk adjustment submission deadline-2024.
Why RAAPID has the Edge
RAAPID is more than just a service provider; it’s a strategic ally in your mission to deliver high-quality, value-based care.
Here’s why our partners prefer us
- Cutting-edge Technology: RAAPID utilizes clinical Neuro-Symbolic AI-powered risk adjustment technology, streamlining patient chart reviews and retrospective audits. This technology ensures faster analysis, higher accuracy, and lower costs than traditional methods.
- Rigorous Quality Control: With stringent quality control processes, RAAPID guarantees accurate coding and compliance with regulatory requirements. This minimizes audit risks for health plans while maximizing revenue potential.
- Top-notch Security Measures: RAAPID employs advanced encryption techniques to safeguard data during transit and storage, ensuring the highest level of security. Additionally, its data centers comply with HIPAA standards, offering redundancy and disaster recovery capabilities to prevent data loss.
End Note
By teaming up with RAAPID, health plans can prioritize the timely submission of Risk Adjustment Data to CMS, ensuring optimized reimbursements & outstanding care for members while entrusting compliant HCC coding to a dependable ally committed to accuracy, financial stability, and security.
Let’s collaborate to elevate your Risk Adjustment journey and seamlessly supplement your endeavors.
