MA Risk Adjustment Should Include Audio-Only Telehealth Diagnoses

Audio-only diagnoses should be factored into Medicare Advantage risk adjustment, Better Medicare Alliance (BMA) stated in a letter to CMS which HealthPayerIntelligence received by email.

“We believe that the ten guardrails CMS proposed in their entirety are unworkable, place an undue burden on health plans and clinicians, and detract from the focus on providing high- quality, accessible care during this period of social isolation,” BMA explained.

Telehealth in general has been critical to payer strategies surrounding the coronavirus pandemic. However, audio-only visits appear to be in higher demand than audio-video visits, with audio-only visits making up over two-thirds of the total telehealth visits for some health plans, BMA noted.

In early May 2020, CMS expanded telehealth reimbursement to include audio-only services. Now, CMS is working to solidify how these audio-only services will or will not factor into risk adjustments for Medicare Advantage plans.

The BMA response letter listed a few reasons why clinicians should be permitted to obtain diagnoses for risk assessment through audio-only telehealth, especially in light of current care delivery limitations due to coronavirus. The list included that

• Medicare Advantage patients do not have equal access to the technologies necessary for telehealth
• The clinical data will be limited for populations of patients who do not have access to any other type of telehealth
• Audio-video telehealth tools have already received permission to collect diagnoses for risk assessment

BMA offered its feedback about the ten guardrails which CMS provided for audio-only telehealth risk adjustment.

The first CMS guardrail dictated that clinicians may gather risk adjustment diagnoses for audio-only solely when the patient is an established patient. BMA requested more clarity surrounding the term “established patient” and suggested that it complement the definition of a “new patient” in the Medicare Claims Processing Manual. That would mean that an established patient was any patient who had visited the physician or the physician group practice in the past three years.

The second CMS guardrail said to limit diagnoses to patients that had previous encounters which were submitted for risk adjustment.  BMA suggested eliminating this guardrail and permitting new conditions to be counted toward risk adjustment, as are consistent with the requirements that govern telehealth visits.

CMS said that diagnoses over the phone would only be allowed when they result from six evaluation and management codes paid for by traditional fee-for-service Medicare. But the BMA replied to this guardrail saying that diagnosis codes from audio-only calls should be managed with the same codes that would be applied to face-to-face or audio-visual visits.

The fourth guardrail recommended that audio-only diagnoses should only be initiated by the patient, with lab results being the only time that a provider should initiate contact through a phone call. However, BMA found that this rule was incompatible with typical patient-provider communication. The alliance suggested that patients should be allowed to indicate their preferred form of contact and that audio-only should be an option.

Fifth, the guardrails allow diagnoses for risk adjustment to be captured if it is by two or more providers not in the same practice. BMA pointed out that patients handling chronic disease management will often go to just one provider. This would actually incentivize placing more of a burden on the patients to go to multiple providers for the sake of risk adjustment.

The sixth guardrail stated that audio-only visits related to an accepted list of lab tests. But BMA demonstrated that there were multiple ways to confirm a diagnosis, not just through lab testing, and that these other forms of confirmation were acceptable for risk adjustment in face-to-face and audio-video visits. Audio-only should have the same guidelines, BMA insisted.

Seventh, CMS may require more documentation for proof of an audio-only diagnosis than normal. BMA found that such a stipulation would actually increase providers’ administrative burdens, running counter to CMS commitments to decrease provider burden during the coronavirus pandemic.

In the eighth and ninth guardrails, CMS sought to review all audio-only encounters by having plans self-audit through CMS-approved independent auditors or use a plan attestation to review the accuracy of the audio-only submissions. A 100 percent audit as suggested would be very demanding administratively, BMA pointed out, not only for health plans but also for providers and hospitals. Instead, policy should align with Traditional Medicare requirements and not increase potential penalties.

Lastly, CMS suggested capping on how diagnoses may increase plans’ average risk scores over the previous year. BMA found that this would incentivize inaccurate risk assessments which would, in turn, injure Medicare quality of care.

“We join with many of those stakeholders in urging CMS to permit diagnoses obtained during audio-only telehealth visits to count towards a beneficiary’s risk score and to do so in a way that is workable for health plans, providers, and beneficiaries. We ask that this decision be made as soon as possible to ensure that data collected in 2020 is as complete and accurate as possible amid the COVID-19 emergency,” BMA stated.