Risk Assessment

A Look Inside the Four Most Common Value-Based Care Arrangements

January 25, 2024 - A simple explanation of value-based care is rewarding quality over quantity. However, value-based care arrangements differ in how they determine payments and the level of risk that is assumed. As healthcare organizations warm up to the idea of value-based care, CMS and commercial payers must choose which kind of arrangements they will offer to their provider partners. Value-based care...


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What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans

by Victoria Bailey

Cigna’s recent brush with False Claims Act violations serves as a reminder that Medicare Advantage organizations should be routinely assessing their risk and compliance activities. The Department of Justice (DOJ) announced in...

Medicare Advantage RADV Rule May Prompt More Legal Action from Payers

by Victoria Bailey

Payers have not reacted lightly to the Medicare Advantage Risk Adjustment Data Validation (RADV) final rule. Major payer Humana made the strongest display of disapproval by filing a lawsuit against CMS that seeks to invalidate the...

Medicare Advantage Risk Adjustment Model Accuracy May Vary By Race

by Kelsey Waddill

The CMS-Hierarchical Condition Category (HCC) model used for Medicare Advantage risk adjustment may inaccurately estimate beneficiaries’ spending depending on the race or ethnicity of the...

The Future of Medicare Advantage Risk Adjustment Data Validation

by Kelsey Waddill

Around four years passed between when CMS proposed the new rule on Medicare Advantage risk adjustment and when the Medicare Advantage Risk Adjustment Data Validation final rule was published. As stakeholders review the long-awaited final...

Problems with Medicare Advantage Payment System Contribute to Overpayment

by Kelsey Waddill

The Medicare Advantage program has serious structural problems that lead to overpayment and policymakers must take action on MedPAC’s recommendations in order to create a more cost-effective...

Alzheimer’s Risk Adjustment Increases Detection, Medicare Spending

by Victoria Bailey

Incorporating Alzheimer’s disease and related dementias (ADRD) Hierarchical Condition Categories (HCCs) into risk adjustment for Medicare Advantage and Medicare accountable care organizations...

How COVID-19 May Impact MA Risk Scores, Payments in 2022, 2023

by Kelsey Waddill

CMS does not anticipate coronavirus-related expenditures including deferred care to impact 2022 healthcare spending, but the pandemic might impact Medicare Advantage risk scores in contract year 2023,...

CMS Finalizes ACA Risk Adjustment, Error Rate Calculation Changes

by Kelsey Waddill

CMS has issued a final rule to regulate the Affordable Care Act risk adjustment data validation program. The risk adjustment data validation program, run by HHS, certifies the integrity of data that...

How Population Health Tactics Fortify COVID-19 Member Engagement

by Kelsey Waddill

As the healthcare system reels from the coronavirus, payer success in member engagement relies in part on effective implementation of population health management strategies. For more coronavirus...

Spending, Prescription Histories Identify Future High Cost Members

by Thomas Beaton

An individual’s healthcare spending and prescription drug histories are among the most accurate predictors of future high costs, according to a new Society of Actuaries (SOA) report. SOA used...

Using Social Determinants of Health for Risk Stratification

by Thomas Beaton

Engaging in meaningful risk stratification of beneficiaries requires accurate data that can highlight opportunities to reduce costs and improve outcomes for plan members. In order for payers to...

Medicare Advantage Consumers Seek New Plans as Risk Scores Rise

by Thomas Beaton

Medicare Advantage (MA) consumers who switch to new health plans may have higher risk scores than beneficiaries who are content with their current options, indicates a Congressional Budget Office (CBO)...

AHA to CMS: Continue Funding ACA Cost-Sharing Reductions

by Thomas Beaton

CMS should continue to fund the cost-sharing reductions (CSRs) that keep the Affordable Care Act insurance marketplaces relatively stable, the American Hospital Association (AHA) said in a comment...

How Risk Adjustment Challenges the Health Insurance Market

by Vera Gruessner

Ever since the provisions of the Patient Protection and Affordable Care Act came into effect on January 1, 2014, healthcare payers have been unable to deny health insurance or charge larger premium...