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Advantmed Assists as Medicare Advantage Payers Prepare for Magnitude of 2019 Proposed Changes to CMS-HCC Risk Adjustment Model, Early Draft Release Signals Complexity
[January 10, 2018]

Advantmed Assists as Medicare Advantage Payers Prepare for Magnitude of 2019 Proposed Changes to CMS-HCC Risk Adjustment Model, Early Draft Release Signals Complexity

Responding to the early release draft of 2019 Proposed Changes to the CMS-HCC Risk Adjustment Model, and subsequent releases from CMS in February and April expected to reflect required, significant changes to the Medicare Advantage (MA) model, Advantmed, LLC, an integrated risk-adjustment optimization and quality improvement company, will lend its expertise and experience to assist MA leaders in preparing for this anticipated, complicated transformation.

"This is a real break from the normal CMS cadence of announcements, and offers strong signals to the MA community that serial changes are underway," says Jay Baker, senior vice president, quality and risk adjustment solutions. "In support of our current and potential MA clients who face this new complex regulatory environment, our senior leadership team is stepping up to help them deal with the reality of what needs to be accomplished in a very short timeframe. Adjusting to these changes will require specialized expertise, since financial and clinical adjustmets will affect fiscal and operational processes that impact plan performance, patient care and compliance."

While it is likely that refinements will be made to the final document and actual implementation following the 60-day comment period, the highlights of the current draft include:


Based on the 21st Century Cures Act signed by President Obama in December 2016, the new MA model and risk scores must be modified to account for evaluating the addition of mental health, substance use disorder, and chronic kidney disease conditions. MA plans may be required to consider the total count of conditions indicated. CMS is reviewing with the industry two methods counting all conditions or only conditions used in the risk adjustment model. CMS has indicated they will implement changes phased in over three years (2019-2022).


Model coefficients may require updates at least every three payment years to maintain accuracy. The proposal uses Date of Service (DOS) 2014 to predict costs in 2015, resulting from the ICD-10 introduction in 2015 which caused a serious data quality issue; the next calibration will use DOS 2016 or later. Changes propose new coefficients based on more current data collected.


The new HCC clinical model will expand the suspecting and targeting for community populations to conditions and specialties that have not really been previously targeted, such as behavioral specialists and drug and substance care. Targeting expansion is required to ensure accurate counts, and complexity will increase since all will be phased in concurrent to phasing in the Encounter Data Processing System (EDPS) over the Risk Adjustment Payment System (RAPS).

"Many MA plans lack the resources to effectively address these changes, and are invited to take advantage of the assistance that our team can offer," says Baker.

Advantmed can help to navigate the CMS proposed changes for MA plans. Email for more assistance.

About Advantmed, LLC

Advantmed, LLC is a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs. Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members. For more information on Advantmed's solutions visit

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