Telehealth Increase Underscores Need for MA Risk Adjustment

Just days after CMS mentioned in its final 2021 Medicare Advantage and Part D rate notice that it would issue separate guidance on the topic of telehealth and risk adjustment (see story, p. 1), the Trump administration unveiled a major shift in telehealth policy by giving plans new latitude to apply diagnoses from telehealth visits for risk adjustment purposes. While this removes a longstanding barrier to MA plans’ use of the technology, it remains unclear whether CMS is making a permanent policy change.

“The 2019 Coronavirus Disease (COVID-19) pandemic has resulted in an urgency to expand the use of virtual care to reduce the risk of spreading the virus,” said the agency in an April 10 memo to plans. “CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter.”

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