HHGM Concepts are not Going Away; Cropping up Elsewhere in Healthcare

Recently, the Centers for Medicare and Medicaid Services released the first part of its 2019 advance notice of changes for Medicare Advantage capitation rates and Part D payment policies.

The release includes a change in the percent of encounter data used for payment. “For 2019, CMS proposes to calculate risk scores by adding 25 percent of the risk score calculated using diagnoses from encounter data and fee-for-service diagnoses with 75 percent of the risk score calculated with diagnoses from the risk adjustment payment system, or RAPS and fee-for-service diagnoses.” (Healthcare Finance News)

The new method increases the percent of fee-for-service data in the risk adjustment to counterbalance the HMO’s gaming of the system to increase the level of patient illness in order to increase their payments.  This parallels elimination of therapy visit levels determining reimbursement under the Home Health Groupings Model (HHGM).  Additionally, the increased importance of the number of patient conditions is similar to the co-morbidity adjustment in HHGM.

Clearly, CMS is following the same playbook throughout all of the healthcare delivery system.  Agencies need to know the impact HHGM would have had on their agency since the concepts behind it are not going away.

We have just developed a model in conjunction with McBee Associates which shows the impact of HHGM on agency reimbursement compared to the current methodology. Please contact us at 215-657-7373 or rchesney@nullhealthmr.com to learn how we can help you understand the potential impact on your agency.