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HRSI has partnered with Transtreme, a clinician-led organization that provides Risk Assessment services for the Medicare Advantage population. Through their Embedded Nurse Practitioner model, Transtreme assists patients by accessing their medical records to confirm existing diagnoses as well as identifying new, suspected, and dropped codes and conditions. Their program also helps providers increase their capitation rates by accurately identifying the risk adjustment value of their Medicare Adjustment population.

The Rise of Medicare Advantage

An increasing number of Americans are shifting their traditional Medicare coverage to Medicare Advantage. In fact, over 32 percent of the Medicare population is enrolled in Medicare Advantage. That is triple the amount from when the program was launched in 2003.

Because Medicare Advantage plans accept risk by enrolling individuals with a wide variation in health and disease status, the Center for Medicare and Medicaid Services (CMS) uses Risk Adjustment and other related policies to compensate these plans. It is in the best interest of the patient, provider, and payer to ensure the Risk Assessment is accurate.

Why the increase in Medicare Advantage enrollment?

Change is always difficult for patients and a big reason Medicare Advantage is drawing appeal is in its familiarity. Its health plan model is similar to the programs they were enrolled in during their employment years. The plans have networks and you pay for medical services as you go.

A major difference between Medicare Advantage vs. Medicare – Medicare Advantage is not run by the federal government. The government sets the rules and guidelines and provides funding, but the plans are administered by private insurance companies. With that, Medicare Advantage offers a broader range of options, the most popular being HMO and PPO plans. All Medicare Advantage plans are obligated to cover Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) and many offer Medicare Part D (prescription plans). Medicare Advantage is the new Medicare Part C, previously known as Medicare +Choice. It can offer additional benefits, such as routine vision and dental visits or even 24-hour nurse hotlines.

Here is a short list of the benefits realized by being enrolled in Medicare Advantage.

Medicare Advantages

  • Patient satisfaction with longer visits
  • Integration of personal medical history
  • A sharp focus on preventative care and early intervention
  • Offers an out-of-pocket maximum to protect beneficiaries
  • Attention to identifying and treating chronic disease
  • Deploys innovative models for delivering and coordinating healthcare
  • Payments are risk adjusted to reflect the specific characteristics of each enrolled beneficiary – including demographics, Medicaid eligibility, and health status

Risk Adjustment Assessment

Risk adjustment is essential in accounting for the overall health and anticipated medical costs of each individual enrolled in a health plan. To determine levels of funding, CMS calculates a risk adjustment score to pay Medicare Advantage plans for the risk of the beneficiaries they enroll. This is more accurate (and fair) than simply calculating an average amount for beneficiaries.

The score – or Risk Adjustment Factor (RAF) – affects every physicians reimbursement. The score reflects the severity of risk due to several factors including (but not limited to) health conditions, gender, family history, aged/disabled status, and recent history of medical check-ups/care.

Patient Assessment

A gap in the Medicare Advantage system for beneficiaries and their providers is a thorough and accurate assessment of their overall health care. Without access to medical records and routine visits, assessments are often inaccurate or incomplete, which affects their overall RAF score. A lower RAF score translates into reduced federal funding.

While these assessments by home-based vendors throughout the country are flawed and lack patient trust, the unique Transtreme model of conducting assessments has enjoyed immense success. Its embedded, in-clinic model fosters relationships between the Transtreme Nurse Practitioners (NPs) and patients. Physicians enjoy the partnership and value-added services the NPs provide, while patients visit a familiar, comfortable environment that allows for medical record access by NPs, reduced skepticism from patients, and closure of *HEDIS and Star Rating gaps right at the point of service.

The financial success of the Transtreme model has been repeatedly proven with clients in California, Texas, Arizona, Nevada, and Hawaii for over five years. HRSI, based in the Commonwealth of Pennsylvania, is collaborating with Transtreme to expand upon the success they’ve enjoyed with their Embedded Nurse Practitioner model on the west coast.

To schedule an appointment with HRSI, visit their website at www.hrsi1.net. Their specialist in Medicare Advantage and Risk Adjustment Assessment is Vice President for Sales and Marketing, Chad Wallace.

*HEDIS – Healthcare Effectiveness Data and Information Set