The Risk Adjustment Policy Committee offers policy guidelines for risk adjustment involving telehealth services.


The RISE Risk Adjustment Policy Committee addresses the public policies involving risk adjustment and quality payments for value-based programs, most particularly Medicare Advantage (MA) and the Affordable Care Act (ACA) marketplace. Our goal is to support the crucial work of health plans to collect and report complete and accurate data necessary for risk adjustment and quality assurance programs that are fundamental to well-functioning insurance markets. These activities also provide important insights informing health plan innovations in population health management and understanding and documenting the social causes of disease that we all know we need to address.

Now with the dramatic shift in patient care patterns due to the COVID-19 public health emergency, the industry recognizes the need to adapt policies for the proper use of telehealth technologies. The first response was to launch directly into telehealth as an emergency measure as many Americans retreated from in-person office visits for much of their chronic care needs. Telehealth most definitely increased individuals’ access to health care services during this time. The continued likelihood of increased adoption of telehealth during and after the pandemic raised numerous issues, including how best to accurately capture and document chronic health conditions. These issues have been addressed by the Centers for Medicare & Medicaid Services (CMS), which has issued standards for coverage and provider payment for telehealth and the permissible use of diagnoses based on information learned during telehealth encounters for risk adjustment purposes that differ for the MA and ACA marketplaces. 

Our deliberations as the Risk Adjustment Policy Committee led us to consider useful policy guidelines for risk adjustment involving telehealth services. We view our suggestions as a complement to the work sponsored by the NCQA’s Taskforce on Telehealth Policy to further our shared goals of promoting the collection and use of clinically relevant, accurate data that are critical to ensuring all individuals have access to high quality, affordable health care.

The Taskforce on Telehealth Policy

The Risk Adjustment Policy Committee commends the Taskforce on Telehealth Policy, which represents a broad group of stakeholders across the industry. As reported in its webinar and supporting documentation, the Taskforce on Telehealth Policy’s main focus was on three major areas:

Patient Safety: Telehealth can enhance patient safety by preventing care delays, reducing exposure to pathogens, and minimizing travel needed for in-person care. Policymakers should fund research on telehealth best practices for patient safety and update existing patient safety event reporting structures to incorporate telehealth.

Program Integrity: Emerging artificial intelligence tools to audit claims and other data have the potential to make it easier to detect fraud. In the case of telehealth, investigators can uncover Internet Protocol (IP) addresses and other digital signatures (e.g., date/time stamps) to identify bad actors. Integrating these tools into existing enforcement mechanisms may eventually reduce telehealth program integrity risks.

Quality: Telehealth is essentially a setting or modality of care, rather than a type of care. This means that it should be held to the same standards for risk adjustment and quality measures as in-person care where appropriate. In cases where the unique characteristics of telehealth dictate a change in a given measure, it should be adapted, rather than reinvented or developed from scratch. Where evidence and standards of care allow, measure stewards should do so without altering standards and outcomes expected for services provided via telehealth.

RISE Risk Adjustment Policy Committee Policy Recommendations

The recommendations of the Taskforce on Telehealth Policy are well-founded, and the RISE Risk Adjustment Policy Committee fully supports them. We are in complete agreement with its findings that telehealth is part of the evolution of health care into the digital age and not just another type of health care and that it can be a critical tool in advancing a well-coordinated and patient-centered, value-optimized health system. Building on that premise, the RISE Risk Adjustment Policy Committee recommends further development of standards applying in all markets based on the following principles:

  1. Telehealth visits are clinical encounters that yield tangible value based upon their efficacy in assessment and treatment. This means that the appropriateness of using this technology must be assessed first by clinicians under a variety of circumstances (i.e., audio visits with and without a video component). Discerning which health conditions are treatable remotely requires the input of physicians who normally care for patients with those conditions now. Those decisions should consider whether conditions are acute or chronic, if a telehealth visit identifies a new diagnosis, and whether the patient is already in the care of the attending physician.
  2. Telehealth visit documentation must follow the same guidelines applicable in any other setting. There is no reason that the requirements of ICD-10-CM guidelines or the AHA Coding Clinic would not equally apply to telehealth visits.
  3. While specific claims codes are required for place of service and only certain CPT/HCPCS/or related codes qualify telehealth visits for payment, all other information should fit in the normal claims or encounter submission formats. Because Medicare regulations for payment have specific ways for flagging telehealth visits, those protocols are necessary for payment and qualification of encounters for recognition and acceptability.
  4. If all three conditions above are met, telehealth visits should qualify for risk adjustment purposes irrespective of line of business. The first three conditions establish that the diagnostic codes are valid and supportable under Risk Adjustment Data Validation criteria when conducting a chart audit, and therefore should be determined appropriate for risk adjustment purposes.

When meeting these conditions, most importantly that telehealth is clinically appropriate to meet the individual’s needs and the data collected during the encounters are accurate, we believe these standards should apply across markets. That is, except where state laws override federal guidelines for the ACA marketplace where telehealth may not be acceptable, the Medicare program should be aligned with MA, the ACA marketplace, and Medicaid programs.

These recommendations will also have uses as we consider how best to use information gathered during telehealth encounters for Stars programs and others holding health plans accountable for the quality of care provided to enrollees. Given the vast and rapid adoption of telehealth on the part of both clinicians and patients, the RISE Risk Adjustment Policy Committee agrees that telehealth will remain a vital tool in the continuum of clinical management of health conditions. The development of consistent, consensus standards is therefore essential not only during the pandemic but also once we are past this crisis.

Health plans strongly support the collection of clinically relevant, accurate data that supports all the activities described above that are fundamental to providing our enrollees with high quality, affordable care. We look forward to continuing to work with CMS and other policymakers to ensure these data remain a reliable foundation for these activities to address ongoing technological innovations in care, including telehealth, as they develop.

Kevin Mowll, former executive director, RISE Association, on behalf of the RISE Risk Adjustment Policy Committee