What is Risk Adjustment?
We have developed a risk adjustment solution that is designed to help health plans, providers and patients achieve better outcomes, together. By increasing the patient engagement and wellness, improving coding accuracy and compliance, and identifying and closing gaps in care, we ensure that everyone will thrive So let’s start with some basics about a value-based plan …
About Risk Adjustment
Risk Adjustment, Revenue Potential You Don't Want to Miss
Risk adjustment is a form of predictive modeling introduced by the Medicare Modernization Act of 2003. It gauges the risk that a member will incur medical expenses above or below an overall average over a defined period of time. Risk adjustment assists in the financial forecasting of future medical need. The more severe or complex a diagnosis, the higher the risk value that is assigned. The concept was introduced to minimize the incentive to choose enrollees based on their health status.
A risk-adjustment value is assigned to each diagnosis code that falls into the payment model. The ICD-10 codes are then grouped into an HCC, or hierarchical condition category. HCC categories are related both clinically and financially. Unlike hospital DRGs, HCCs are cumulative: each additional HCC in an unrelated disease category is factored into the risk profile.
HCC Audits
Risk coding affects many areas of your practice. Improved documentation and coding leads to better patient care. They are the primary means of communicating the patient record for specialty care to health plans and CMS. Accurate documentation also improves quality reporting and efficiency when responding to regulatory requirements, such as HEDIS/QARR reviews and risk-adjusted data validation (RADV) audits. Financially, it helps achieve greater accuracy in the documentation of key quality metrics associated with payments.
Retrospective
Prospective
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