Risk Adjustment Process
During the first half of each year (January through June) payments from CMS to
the health plan are an estimate, based on risk adjustment scores from data
submitted by the previous September, covering dates of service for 12 months
ending the previous June.
The January, 2010 payment was based on risk adjustment data submitted by
September 1, 2009 (the previous September) for dates of service from July 1,
2008 through June 30, 2009.
On July first each year, plans begin receiving the "correct" or trued-up payment
for the current year, based on all dates of service in the previous year. At that
time (actually in August and sometimes even later), health plans receive a
payment to correct what should have been paid from January through June.
So, the July, 2010 payment will be based on risk adjustment data from dates of
service between January 1, 2009 and December 31, 2009, submitted by March 7,
2010.
You can submit codes for 2010 dates of service (affecting payment for 2011) up
until January 31, 2011. If these codes increase what the correct monthly payment
to the plan should have been, then in September of 2010 the plan receives
payment for that difference, representing the amount the plan was underpaid.
With the Risk Adjustment Data Validation (RADV) push by CMS it is even more critical to ensure medical record and encounter accuracy. SeaCliff Resources has developed an audit solution to address your RADV concerns.
Of course, if the data submitted shows that the plan was originally overpaid, the
result is a negative adjustment to plan payment.
