Health care organizations and industry trade groups continue to put pressure on the Centers for Medicare & Medicaid Services (CMS) to allow audio-only encounters to be included in Medicare Advantage (MA) risk adjustment.
Health care industry groups led by the Alliance of Community Health Plans (ACHP) have urged CMS to allow diagnoses obtained via audio-only telehealth encounters for risk adjustment purposes. The organizations, which include AHIP, America’s Physician Groups, AMGA, Better Medicare Alliance, and Blue Cross Blue Shield Association, represent patients, providers, payers, employers, and health systems across the country.
The move, they say, is imperative to ensure the accurate capture of health costs, stabilize premiums, and maintain robust benefits. Including all encounters in risk adjustment will also allow clinical care teams access to information necessary to comprehensively manage patient care.
In a June 3 letter to Department of Health and Human Services Secretary Xavier Becerra and CMS Administrator Chiquita Brooks-LaSure, the groups said that during the COVID-19 pandemic, Medicare beneficiaries have relied on telehealth to safely receive care. Access to these services is essential for seniors living with chronic conditions who are at greater risk from complications from COVID-19.
During the pandemic, CMS has only allowed MA plans to use video-enabled telehealth visits to document diagnoses. The agency has not extended the flexibility to audio-only telehealth encounters, which has created unnecessary inequity in communities across the country, according to the groups. The policy puts communities that already experience health disparities at a disadvantage. Rural, minority, socioeconomically disadvantaged, elderly, medically fragile, and otherwise vulnerable populations are all less likely to have access to video-capable technology or the infrastructure or ability to make use of it, they wrote.
Indeed, 40 percent of MA enrollees earn less than $25,000 annually, and of those, 35 percent do not have access to broadband internet in their homes. For these seniors, audio-only telehealth is the only safe and available option to receive care. A recent issue brief from the Kaiser Family Foundation found that 56 percent of the Medicare beneficiaries who used telehealth during the pandemic only used audio-only modes to receive care. The rates were higher among those 75 and older, Hispanic-Americans, rural beneficiaries, and dual-eligible beneficiaries.
“Not allowing the health status of seniors who have utilized audio-only services for risk-adjustment provides an incomplete picture of the health of the Medicare population and unintentionally makes seniors appear healthier than they are,” they wrote.
The policy is also unfair considering CMS allows plans on the federal Affordable Care Act (ACA) marketplace to count both video and audio telehealth in their encounters for risk adjustment. “It is fundamentally unfair to seniors to apply different standards from one federal program to another, unreasonably limiting the ability to fully and properly document risk to select programs,” the letter said.
The groups also asked that CMS allow MA plans to use a 24-month look-back period to supplement 2020 data for the calculation of 2021 risk scores, which would mitigate the pandemic’s effects on comprehensive, accurate diagnostic data for enrollees. Allowing health plans to supplement 2020 encounter data with data from 2019 would alleviate the negative impact of under-risk-adjusting as a result of care delivered through unallowable encounters during the pandemic.
The lookback period, they argued, would not inflate risk scores because using 2019 data would not capture new membership or any risk scores not previously documented.
The current telehealth flexibilities are expected to remain in place throughout the public health emergency, but CMS said it will take congressional action to make some flexibilities permanently. Bipartisan legislation has been introduced in the House of Representatives that would allow providers to offer audio-only telehealth services to MA enrollees and the services would count toward MA risk adjustment.
The RISE Risk Adjustment Policy Committee also released a position paper in October 2020 outlining its policy recommendations for telehealth and when the visits should qualify for risk adjustment purposes. The committee stressed that the policies should be consistent across the Medicare program, MA, the ACA marketplace, and Medicaid programs.