[Federal Register Volume 84, Number 125 (Friday, June 28, 2019)]
[Proposed Rules]
[Pages 30983-30984]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-13891]
[[Page 30983]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 422
[CMS-4185-N4]
RIN 0938-AT59
Medicare and Medicaid Programs; Risk Adjustment Data Validation
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule; request for additional comment; announcement of
the release of additional data.
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SUMMARY: This document summarizes actions taken to date, requests
public comment on additional subjects, and announces that CMS is
releasing additional material, including study data, related to the
Risk Adjustment Data Validation (RADV) provisions of the proposed rule
titled ``Medicare and Medicaid Programs; Policy and Technical Changes
to the Medicare Advantage, Medicare Prescription Drug Benefit, Program
of All-inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service,
and Medicaid Managed Care Programs for Years 2020 and 2021'' that was
published in the November 1, 2018 Federal Register, 83 FR 55037. The
comment period for the RADV provisions of this proposed rule ends on
August 28, 2019.
DATES: The comment period for CMS RADV provisions (that is, section
II.C.2. of the November 1, 2018 proposed rule and proposed Sec. Sec.
422.300, 422.310(e) and 422.311(a) of the regulation text) closes at 5
p.m. on August 28, 2019.
ADDRESSES: In commenting, please refer to file code CMS-4185-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-4185-P, P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-4185-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Jonathan Smith (410) 786-4671 or
Joanne Davis (410) 786-5127.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to
view public comments.
I. Request for Public Comment
On November 1, 2018, we published a proposed rule containing
provisions related to the Risk Adjustment Data Validation (RADV) audit
program, 83 FR 55037 through 55041 and 55077, including the proposal
not to apply a Fee-for-Service Adjuster (FFS Adjuster) in any RADV
extrapolated audit methodology. That proposal rested on two grounds.
First, we conducted a study which indicated that diagnosis error in FFS
claims data does not lead to systematic payment error in the Medicare
Advantage (MA) program. Second, we suggested that it would be
inequitable to correct any systematic errors made in the payments to
audited plans only. We continue to welcome public comment on this
proposal. We are also seeking comment on whether 42 U.S.C. 1395w-23--
and in particular clause (a)(1)(C), which requires risk adjustment in
subclause (a)(1)(C)(i), mandates a downward adjustment of risk scores
in subclause (a)(1)(C)(ii), and includes provisions about risk
adjustment for special needs individuals with chronic health conditions
in subclause (a)(1)(C) (iii)--mandates an FFS Adjuster, prohibits an
FFS Adjuster, or should otherwise be read to inform our proposal not to
apply an FFS Adjuster in any RADV extrapolated audit methodology.
II. Summary of Prior Notices
Since we published the FFS Adjuster Study on October 26, 2018,\1\
we have published several related notices.
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\1\ The Executive Summary and Technical Appendix of the study
are both available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Resources.html.
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On December 27, 2018 (83 FR 66661), we announced an extension of
the comment period for the RADV provisions until April 30, 2019 and a
plan to release data underlying the October 26, 2018 FFS Adjuster
Study.
On March 6, 2019 (84 FR 8069), we announced the release of data
underlying the FFS Adjuster Study, both through the Office of
Enterprise Data Analytics (OEDA) and on the Private Plans Team website.
Data made available to the public through a data use agreement included
all of the following:
An input file originating from a dataset that Research
Triangle Institute (RTI) supplied. It represents the calibration data
that RTI used for the Centers for Medicare and Medicaid Services
Hierarchical Condition Category (CMS-HCC) model version that CMS used
to calculate 2009 MA payments.
An input file containing medical record review findings
from a RADV-like review that CMS undertook on a sample of calendar year
2008 medical records.
FFS data containing 10 datasets that represent the entire
5 percent sample of all final 2004 and 2005 diagnosis codes used for MA
model calibrations through 2011.
An HCC file containing the mapping from International
Classification of Disease, 9th Revision diagnosis code to Version 12 of
the CMS-HCC model. Diagnosis codes have been modified to remove
decimals.
A file consolidating MA data for beneficiaries who meet
eligibility criteria for Contract-Level Risk RADV audits from three
sources: The adjusted Monthly Membership Report (MMR), the Model Output
File (MOF), and the CMS Enrollment Database (EDB).
A file consolidating MA data for beneficiaries who did not
meet all eligibility criteria for the Contract-Level RADV audits from
three sources--adjusted MMR, MOF, and CMS EDB.
Additional documentation and data related to the RADV FFS
Adjuster Study was posted on the Private Plans Team website at https://
www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/
Medicare-Risk-
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Adjustment-Data-Validation-Program/Resources.html. This data included a
RADV Data Dictionary and Provisional Coefficients workbook.
On April 30, 2019 (84 FR 18215), we announced an additional
extension of the comment period for the RADV provision until August 28,
2019. We also announced that we would be releasing additional data
underlying the FFS Adjuster Study, including additional data containing
Protected Health Information, to all parties who entered an applicable
data use agreement and paid the required fee. This data has been
available since June 14, 2019. The forms and instructions to request
this data and previously released data remain available via the CMS
website at https://www.cms.gov/research-statistics-data-and-systems/files-for-order/limiteddatasets/. Updates to existing documentation
related to the study data, as well as additional data without Protected
Health Information, were posted on the CPI Private Plans Team website
on April 25, 2019.
III. Release of Additional Study Material and Further Request for
Public Comment
We have now replicated the FFS Adjuster Study and published a
summary of that replication as an addendum to the study at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Resources.html. The
results of the replication are broadly consistent with the initial
implementation of the study. The purpose of this replication was to
allow us to both test our initial results and release a more complete
set of underlying data. Certain intermediate data elements not saved as
part of the implementation of the initial study have been preserved and
published in the addendum or at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Resources.htm. In addition, the
addendum contains further discussion of the study's assumptions and
methodology. We are also releasing the programming language used to
implement the replication of the study, available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Resources.html, along
with a description of the technical requirements for use of that
programming language. It is our intention that the release of this
programming language, together with the earlier release of the data
used as inputs, will allow for robust public comment on the FFS
Adjuster Study.
We welcome public comment on that subject, and all subjects raised
in this notice and the notices discussed previously, until 5 p.m. on
August 28, 2019.
Dated: June 21, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2019-13891 Filed 6-27-19; 8:45 am]
BILLING CODE 4120-01-P