Telehealth Visits Will Risk Adjust for Medicare Advantage

Written by Ted Kyi

April 10, 2020

The official guidance which those of us in the risk adjustment community have been waiting for has finally arrived.  Exactly one month after the HPMS memo authorizing MA plans to expand use of telehealth, the agency has announced that diagnoses from telehealth visits will be included in risk adjustment calculations.

The requirements are that the encounter meet the usual face-to-face rules, and that the telehealth use audio and video.

CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter….  Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.

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Ted Kyi
SVP, Business Intelligence & Analytics at Matrix Medical Network

Ted Kyi is a leader in the Business Intelligence & Analytics group responsible for measurement and analysis of current and new products and services at Matrix.  Ted leads the healthcare analytics and data science teams, and is a subject matter expert on risk adjustment and government programs.  He has worked in healthcare analytics for over twenty years.  Prior to joining Matrix, Ted was president of the analytics vendor Ascender Software, and vice president of the consulting firm Infotech Systems Management.