Plans Want Diagnoses From Phone Visits Included in MA Risk Adjustment

A health insurer trade group is calling on the federal government to change Medicare Advantage (MA) risk adjustment calculations to include telephone visits, saying the issue has become urgent due to the pandemic, which has seen in-person visits drop and telehealth visits increase dramatically.

CMS determines MA enrollee risk scores based on diagnoses submitted by MA organizations through the Encounter Data System, which are then used to determine a plan’s risk-adjusted payments. When CMS expanded reimbursement eligibility for telehealth visits as part of its pandemic response, the agency allowed video telehealth visits to be included in risk-adjustment calculations. However, CMS currently does not allow telephone encounters to be included in risk score calculations.

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