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Risk Adjustment Incredible Money Tips

2 November, 2015



Risk adjustment plays a very large role within the health care industry, and especially in connection to how the Centers for Medicare and Medicaid Services allocate funds for plan members. Risk adjustment is centered around the need to determine how much a health plan member is going to cost in terms of services and treatments needed and rendered. It is through risk adjustment that providers are compensated by CMS as well as how much the plan enrollee will have to pay. As the importance of risk adjustment continues to grow and be highlighted by the health care industry providers, the number of types of risk adjustment approaches continues to grow.

In 2011 the Centers for Medicare and Medicaid increased the number of categories within their HCC model from 70 to 87. With this information taking effect there has been more importance placed on the method of retrospective risk adjustment. This type of risk adjustment looks into the history of an individual in order to make sure all categories that apply to them are actually coded. As there are more categories now, it is essential to make sure that none are being missed or overlooked. Health care businesses provide a number of services when it comes to outsourcing retrospective risk adjustment as a way to ensure that a plan member is getting all of the necessary benefits.

Risk adjustment is focused on creating a realistic and precise number for the anticipated cost of a specific patient or individual. This number is based off of the diagnostic codes that are given to that individual through the examination of doctor’s visits, treatments and services provided as well as current health and their medical records. Each health issue is given a corresponding code by CMS. These codes found in the Hierarchical Condition Categories are matched with a monetary value that depicts the likely cost of this type of health issue in terms of services and treatments that will be needed. When patients are not properly coded, or are missing codes that apply to their current health status, it harms not only the health insurance businesses, but also CMS and the patient.

Recently, the centers for Medicare and Medicaid services established a number of new condition categories within their current H CC coding model which in turn makes risk adjustment an even more essential factor to consider. In this case retrospective risk adjustment is necessary to ensure each plan member is receiving all of the benefits that they are entitled to. With the expansion of condition categories I need to review and look over patient’s chart and counter data and claims with these new categories in mind. Retrospective risk adjustment includes a detailed review of past interactions charts and claims data on a patient to ensure that they are being properly coded for all of the necessary health issues they have.

To learn more go to Altegra Health.

To learn more about Retrospective Risk Adjustment go to Altegra Health.



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