Even though the Centers for Medicare and Medicaid Services (CMS) does not use prescription data in assigning risk scores, Rx data can still be a valuable resource for Medicare Advantage (MA) plans. Because the revenue for an MA plan each year is based on member diagnoses incurred in the prior year and submitted within 13 months of the end of that period, MA plans have a meaningful period of time to ensure complete and accurate coding as well as to identify members for disease management and potential drug adherence outliers. Milliman consultants Corey Berger and Brooks Conway provide perspective in this paper.
Health insurers may increase their risk scores on the commercial health exchange by investing resources to ensure that their diagnosis coding efforts are accurate and complete. In this article, Milliman’s Corey Berger illustrates how the return on investment (ROI) associated with more comprehensive coding efforts is mostly independent of the actions taken by other carriers.
We blogged last week about how payment reform is affecting Medicare Advantage. These plans are facing an increasing emphasis on quality and efficiency, both of which are complicated topics. For more on the quality dimension, consider this recent article from HealthWatch by Corey Berger and Eric Goetsch about hierarchical condition categories.