What is the noise surrounding MRA?

What is MRA? | What is the correct score? | How does the score change? 

What is MRA?Medicare Risk Adjustment or MRA is the all new risk adjustment program created by CMS (Centers for Medicaid and Medicare Services) back in 2000. The program utilizes HCCs in an effort to properly identify the acuity level of an MA member and subsequently pay the contracted HMO a Capitation that should cover the cost of the ensuing expenses related to that HCC. The higher the acuity levels, the higher the risk score and the higher the risks score, the higher the capitation rate. HCC consists of 61 disease groupings based on inpatient and outpatient encounters. The HCC assigned to a disease is determined by the ICD-9-CM diagnosis codes that the Plan receives from the medical groups encounter data. Prior to January 2000, CMS reimbursed health plans based solely on a member’s demographic information, (i.e. age, sex, location etc).

What is the correct score?Every Medicare member has a risk score and this score is based on the information that is sent to CMS indicating the acuity level of a member. So if a member is very healthy, and the Primary Care Physician (PCP) submits encounter data to CMS then the risk score for that member will be low, let’s say .300. If a member is ill but controlled, and again the PCP sees the member regularly and submits encounter data then we can see a score of let’s say, .800. If the member is chronic and the PCP is aware, seeing the member and submitting an encounter data, then the score goes up. The key is the score is based on two main components; the PCP encounter submission practice and the true acuity level of the member. Don’t forget, Medicare requires an acuity level recertification every six months or they assume the member is getting better and your score begins to go down.

How does the score change?The score changes when the PCP submits encounter data that reflects the true acuity level of the member.

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