In these times of unprecedented disruption and rapid change, providers and payers need to consider what this new normal will bring to value-based care and payment programs as well as the level of risk these organizations can sustain. The federal and state governments are modifying various rules and requirements to alleviate burdens and enable care, including a focus on the need to support care access through alternate settings such as telehealth. EXL Health has prepared this short brief to share key insights to help our clients prepare for the impact on the management of the most vulnerable at-risk populations through existing value-based and risk sharing programs.

  • Expect greater utilization of telehealth services to assist in managing risk and access to care
  • Care avoidance due to COVID-19 exposure risk may impact chronic condition management, outcomes, and cost
  • Changes to the way care is delivered and paid during the crisis highlights the need for education, robust toolsets, and analytics to inform scenario and action planning
  • Providers in value-based arrangements face even higher levels of financial risk as a direct result of COVID-19
  • Looming patient visit losses and performance impact due to the pandemic may result in Medicare Shared Savings ACO program drop out
  • At-risk organizations are in dire need of data due to the shifting dynamics to help direct resources, outreach and targeted engagement programs
  • Critical deadlines such as quality measures, risk adjustment, and other reportable outcomes are shifting


  • Broadened telehealth services access and funding
  • Expanded Medicare coverage for telehealth services

CMS Guidance and Regulatory Changes

The COVID-19 pandemic has created an urgency to expand the use of virtual care to reduce the risk of exposure to the virus

  • Broadened conditions and expanded risk adjustment eligibility, including guidance on what conditions are assessable and reimbursable under telehealth/virtual care
  • Expanded provider workforce and enhanced definition of who can provide care
  • Loosened eligible telehealth devices and equipment
  • Halted quality measure reporting and RADV audits
  • Provided consistent telehealth service payment guidelines across lines of business (Medicare, Medicare Advantage, Exchange)
  • Opened door for providers to convert how resources are leveraged including approaches for telehealth visits and telephonic patient outreach

Coding and documentation guidelines for Risk Adjustment and Value-based Programs are evolving

  • COVID related CPT/ICD 10 codes and terminology are being added to support documentation and billing
  • New guidelines on codes and modifiers are changing weekly
  • Specificity of diagnosis, query, and symptoms related to COVID-19 are expanding
  • A focus on patient care over documentation to lessen provider and patient burden
  • Diagnoses from telehealth services applies to both submissions to the Risk Adjustment Processing System (RAPS), and those submitted to the Encounter Data System (EDS)

Expanding Value-based and Risk Adjustment Payments

  • CMS expanding eligible telehealth and virtual care visit requirements for payment to Medicare and Medicare Advantage organizations
  • CMS expanded the Accelerated and Advance Payment Program to increase cash flow to providers affected by COVID-19
  • CMS invoked the Medicare Shared Savings Program (MSSP) extreme and uncontrollable circumstances policy for the COVID-19 public health emergency which mitigates the amount of shared losses

Key Takeaways for Consideration

  • Given the importance of virtual telehealth services and access to care, providers need to prepare for this rapid increase in utilization
  • The need for analytics and data transparency to identify vulnerable patients populations, care gaps and risk areas will be important to ensure care continuity
  • Actionable insights to direct provider resources, telehealth services and engagement programs is critical
  • The need for new and evolving services such as coding, outreach, training/education, and surveillance during and post COVID-19 will be needed
  • The importance of appropriate coding and documentation will only be greater for all diagnoses with the changes related to telehealth and COVID-19
  • An increased knowledge set and approach to documentation and coding for telehealth services will be needed, including potential audit and coding correction activities
  • With a focus on patient care over paperwork, new risk patterns and documentation issues will emerge requiring thorough coding audit reviews and provider education
  • Organizations will see a reattribution of members and shifts in panels requiring additional support
  • Resource planning may need to shift to meet the new demands of virtual visits and the requirements of personnel capable of performing these duties
  • As the crisis dissipates, clients should plan for evolving value-based program requirements and performance measurement needs


Contact US