Health Risk Assessments Should Be Done by Primary Care Providers

May 9, 2013

Primary-care and annual wellness visits are essential to the future of healthcare quality and decreased costs, and third-party providers shouldn't disrupt that.

The recent CMS call letter and final notice for Medicare Advantage (MA) rate adjusted payment brought attention to the patient health risk assessment (HRA). Many of the HRAs have traditionally been provided by third-party administrators seeking ICD-9 codes to increase the MA plan's capitated payment. As stated in the call letter, "CMS is concerned that these risk assessments could be used as a vehicle for collecting risk adjustment diagnoses without follow- up care or treatment being provided to the beneficiary by the plan. The purpose of risk adjustment is to measure health status that is related to plan liability and in the case of these assessments, it is not clear that there is plan liability associated with the provision of treatment."

Further, "these MA enrollee risk assessments are often referred to as Health Risk Assessments (HRAs), and they may be associated with an Annual Wellness Visit (AWV)."

Finally to ensure appropriate payment, "CMS also wants to ensure that payments to MA organizations are accurate, that treatment for identified conditions is done when appropriate, and that costs are reflective of treatment. Therefore, CMS will be implementing a data collection and analysis effort in 2013 of diagnoses that are associated with an MA enrollee risk assessment. Beginning with 2013 dates of service, when reporting risk adjustment diagnoses to CMS, MA organizations will be required to flag those diagnoses collected in an MA enrollee risk."

Really, is there any controversy? Should the HRA be completed by a third–party provider contracted by the MA plan or by an appropriate clinical provider in a primary-care setting.

A recent proponent for the third-party provider states "Medicare risk adjustment coding has become vital to obtain the due reimbursement from Medicare. Outsourcing these tasks to a reliable billing company can help reduce the workload. Accurate Medicare risk adjustment coding is necessary for medical professionals and healthcare entities for obtaining the due reimbursement. As Medicare coding should ideally be done by expert professionals, it is best for healthcare organizations and practitioners to outsource risk adjustment coding services to a reliable medical billing company. An experienced medical billing and coding company is fully aware of the billing and coding methodology and provides accurate risk adjustment coding services. These firms are equipped with the latest technologies and skilled Medicare risk adjustment coders (MRA coders) to comply with your requirements and provide accurate coding reports."

Seriously? A reliable billing company can more effectively code a patient’s diagnoses retrospectively or during a non-clinical interview than a physician can prospectively during an annual wellness visit? The latest technologies are not available to physicians? I know that there are products for clinical providers that facilitate ICD-9 coding during an AWV. Do the MA plans want to pay third-party providers for risk assessments and pay the physicians for AWVs?

The primary-care setting and annual wellness visit are essential to the future of healthcare quality and decreased costs. The AWV will identify the patient (AWV as the "gatekeeper" of managed care) with increased clinical and financial risk and the appropriate population health management tools will be employed. There is no logical argument for third-party providers "treasure hunting" for ICD-9-HCC codes.