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What Is MRA

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10 views

What Is MRA

Uploaded by

gagan kadahalli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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What is Medicare

risk adjustment?
Under the Medicare Advantage (MA) program, MA organizations are paid a set premium to cover the costs of healthcare services
provided by their plans. The Centers for Medicare & Medicaid Services (CMS) uses demographic and disease data for each member
to determine the individual premium. The amount of the premium does not vary based on actual use of health care services. This
payment system, known as Medicare risk adjustment (MRA), allows CMS to adjust its premium payments to MA organizations based
on the expected healthcare costs of its members.

The role of the MA plan, physicians and other healthcare providers


Diagnosis data from physicians and other healthcare providers is used to determine whether an individual member suffers from
certain diseases that are expected to lead to higher healthcare costs for that member. CMS requires all health plans to submi t
Health Insurance Portability and Accountability Act (HIPAA)-compliant 837 claims transactions to CMS for Medicare risk adjustment.
All diagnoses submitted for risk-adjusted payment must meet the following criteria:
• Documented in a medical record based on a face-to-face encounter with an approved physician or other healthcare provider
type (e.g., physician, hospital)
• Assigned based on dates of service within the relevant data collection period
• Coded in accordance with standard industry guidelines (International Classification of Diseases, Tenth Revision [ICD-10])
• Based not solely on laboratory or other diagnostic tests, such as radiology reports

MA plans must annually attest that, based on their best knowledge, information and belief, all risk adjustment information submitted
to CMS is accurate, complete and truthful. As part of the provider participation agreement, by submitting claims to Humana,
physicians and other healthcare providers attest to the accuracy of the data, including diagnosis codes, submitted to Humana.
Physicians and other healthcare providers are responsible for maintaining an accurate and complete medical record for each
Medicare patient and must alert Humana to any erroneous data that has been submitted and follow the procedures for correcting
such data. Physicians and healthcare providers are responsible for participating in any Humana medical record reviews or audits
related to documentation and coding, such as the Provider Data Validation (PDV) documentation and coding review.

In addition to facilitating payment accuracy as well as good medical record documentation and coding practices, risk adjustment also
helps ensure that MA plan members receive the care they need for their health conditions, and that they are able to take advantage
of disease management and other programs available through their MA plans. To improve medical record documentation and coding
practices, physicians and other healthcare providers should consider the following suggestions:
• Use an electronic medical records (EMR) system.
• Confirm that all diagnosis codes are included in the claim submission. For professional services, physicians and other
healthcare providers should have the capacity to submit 12 diagnosis codes.
• Ensure procedure and diagnosis codes on the form are current when using a superbill, encounter sheet or checkout form.
• Provide full and accurate documentation – ascertain that diagnoses are supported.
• Purchase and use updated coding books or software each year. Make sure the practice management system is kept
updated.
• Use a certified coder or health information management professional for coding and billing functions.

For more information, please contact <insert Humana risk adjustment representative’s name> at <insert representative’s phone
number, hours of operation, time zone and email address> .

LC14741ALL1021-B

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