MedPAC Votes to Setup MA Withholds to Improve Encounter Data

April 2019 ~

The Medicare Payment Advisory Commission (MedPAC) commissioners have voted, on April 4, in favor of a recommendation that would instruct CMS to use a payment withhold to incentivize Medicare Advantage (MA) plans to submit accurate, complete encounter data and to run MA provider claims through a contractor to ensure encounter data is handled correctly if enough plans don’t submit the data.

The recommendation follows the CMS announcement that it would use a higher percentage of encounter data in 2020 to calculate risk scores. CMS intends to blend 50% of the risk score calculated using diagnoses from the encounter data with the other 50% of the risk score calculated with diagnoses from the Risk Adjustment Process System (RAPS). It seeks to address the panel’s longstanding gripe with incomplete encounter data, which details a Medicare Advantage patient’s health and can include data such as clinical diagnoses and treatments delivered. The commission believes encounter data that the CMS started collecting in 2012 could provide better oversight of Medicare Advantage.

According to MedPAC, “The Congress should direct the Secretary to establish thresholds for the completeness and accuracy of Medicare Advantage (MA) encounter data and rigorously evaluate MA organizations submitted data and provide robust feedback; concurrently apply a payment withhold and provide refunds to MA organizations that meet thresholds; institute a mechanism for direct submission of provider claims to Medicare Administrative Contractors (MAC) as a voluntary option for all MA organizations that prefer this method, and starting in 2024, for individual MA organizations that fail to meet thresholds or for all MA organizations if program-wide thresholds are not achieved.”

The recommendation does not list a percentage that the agency should take from plan payments. MedPAC staff said the earliest CMS could set up new performance metrics and the plan withhold standards for encounter data would be next spring, meaning they would go into effect for 2021.


Source(s): MedPAC: Inside Health Policy; Deloitte; Modern Healthcare; AHA; FierceHealthcare;