Mitigating the impact of COVID-19 on risk adjustment and quality scores

As routine medical services are cancelled or postponed due to COVID-19, prospective risk scores used to pay Medicare Advantage (MA) health plans in 2021 are trending lower than forecasted. Additionally, risk scores for the Health and Human Services (HHS) model used by the Affordable Care Act (ACA) for commercial plans are also trending lower than prior years, according to health plan data compiled by PopHealthCare, Cotiviti’s risk adjustment solutions partner. As the pandemic subsides, health plans should see an increase in demand for elective and routine care, but the limited capacity and re-strategizing required to meet that demand may continue to impact risk adjustment scores and revenue-capturing opportunities.

Despite these disruptions, health plans can use proactive telehealth and remote care strategies to help mitigate the potential negative impact of the pandemic on risk adjustment and quality measurement programs.

Measuring the impact

“Health plans across the country are noting double-digit decreases in the disease portion of risk adjustment scores,” said Arturo Diaz, chief operations officer of risk analytics at PopHealthCare. “While telehealth encounters have increased to historically high levels, overall provider face-to-face encounters are down.”

To understand how this change in routine visits is impacting their risk adjustment scores, MA plans can perform a year-over-year comparison of risk scores from 2019 to 2020 and look for variation. Health plans should not assume they can “catch up” as the pandemic lessens, however. As primary care resurges, providers dealing with pent-up demand and limited availability may prioritize seeing sicker patients, further impacting risk adjustment scores.

“Medicare Advantage plans filing 2021 bids assuming minimal impact to risk adjustment revenue must execute remediation activities to address the identified drop in face-to-face encounters in order to reconcile that drop with their submitted bids,” Diaz added.

Using telehealth to compensate for reduced in-person appointments

As we outlined in a previous blog post, the Centers for Medicare & Medicaid Services (CMS) increased the MA payment growth rate by 4.07 percent for 2021, which could help stem revenue losses related to the pandemic. But to take advantage of these higher rates, health plans need to make up for missed in-person appointments. According to PopHealthCare’s data, plans may still be able to capture up to 95 percent of hierarchical condition categories (HCCs) by using telehealth in lieu of in-person encounters.

Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication, according to CMS. Additionally, the National Committee for Quality Assurance (NCQA) announced guidance on June 5 allowing telehealth capture of 40 HEDIS® measures, meaning telehealth can be leveraged to address both quality and risk adjustment gaps.

For example, health plans can incorporate fecal immunochemical test kits into their telehealth initiatives to satisfy requirements of the Colorectal Cancer Screening (COL) HEDIS measure. These tests can be mailed out and can improve member satisfaction because multiple aims are achieved during one telehealth visit, reducing member contacts.

Another key benefit of telehealth is the ability to reach members in rural areas that may live hours outside a care center. These members may be hesitant to seek care in larger cities or travel to an area experiencing an outbreak, making travel unsafe. In this case, in-home member assessments can be conducted virtually via telehealth visits. By keeping both members and clinicians comfortable and safe, telehealth solves for many concerns and should remain a viable option even as the healthcare system moves toward recovery.

Telehealth challenges for providers

Excluding large medical providers, most providers struggle with effective “face-to-face” telehealth delivery, Diaz noted. Currently, audio-only (telephonic) telehealth visits cannot be used for risk adjustment consideration, despite pushback from organizations such as the Better Medicare Alliance (BMA) and the fact that many provider groups are defaulting to telephonic assessment.

In fact, NEJM Catalyst found that telephonic care is the current telehealth mainstay while video-based visits are taking time to ramp up. Ongoing barriers to video-based care include:

  • Training clinicians
  • Explaining arrival procedures to patients
  • Using interpreter services
  • Getting video equipment to clinicians’ homes

The publication also noted that some attempted video visits have had to be switched to the telephone or less HIPAA-compliant platforms such as FaceTime and Skype.

Roadblocks on the path to 2021 for payers

In review, Diaz offered seven challenges health plans may face in addressing quality and risk adjustment gaps before the end of 2020:

  • Stay-at-home orders that prohibited routine care and closed many provider offices in the first half of the year
  • Limited time remaining in 2020 to close gaps
  • Provider offices struggling to remain open
  • High-risk patients uncomfortable with venturing to doctor’s offices for routine care
  • Patients completing annual assessment telephonically (thus ineligible for risk adjustment determination)
  • Potential risk of a second COVID-19 wave
  • Unknown impact of flu season

He emphasized that health plans, both MA and commercial, should continue perfecting the telehealth model in the event of future COVID-19 waves and continue to treat sick members wherever they are.

“Plans need to improve telehealth technology to support members’ health, mental well-being, and social determinants of health,” Diaz said. “These important member needs won’t be cured with a vaccine.”

Having qualified nurse practitioners and physician assistants to reach members in their homes is critical to substantiate and round-out risk adjustment efforts, particularly during a pandemic, but this can be difficult to execute. That’s why Cotiviti partners with PopHealthCare to add in-home assessments and telehealth functionality to our risk adjustment services. Learn how we support comprehensive member assessments in a member’s residence or alternative setting to improve prospective risk adjustment results and close care gaps.

Read the fact sheet

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).


Ashley McNairy
Ashley McNairy is an experienced senior product director supporting Cotiviti's Risk Adjustment, Quality and Stars, and Consumer Engagement solutions. Her primary responsibility is the successful delivery of our solutions, ensuring they address the most pressing challenges for HEDIS, Star Ratings, member engagement, and retrieval initiatives. Driven by her passion to see improvements in healthcare quality, Ashley takes pride in working with clients to improve their quality initiatives and enable better care for their members.

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