Medical Risk Adjustment: What is it, Importance and Benefits

What Is Risk Adjustment?

Risk adjustment is a yearly process that companies use to reimburse health plans for the cost of bringing on patients.

If one applied risk management, and your health plan has more than the average number of patients with chronic illness, it will be eligible for risk-adjusted payments. If the plan has less than the average number of patients who suffer from chronic medical issues, one may require to pay for the health plan.

The most important factor in a successful risk adjustment, then, is to accurately document the entire burden of disease with precise data and complete documentation.

Why We need risk adjustment Services?

Payers who serve Medicare Advantage beneficiaries receive an annual, per-member fee in exchange for assuming the total obligation (risk) to pay for members’ health care costs.

Prior to 2011 and legislation like the Affordable Care Act (ACA) banned health plans from refusing coverage to people who have pre-existing health illnesses, many insurance companies could reduce their risk by attracting healthy customers and avoiding members with chronic illnesses. This could have meant it would be more difficult for those who suffer from chronic illnesses to obtain insurance for health. The individuals could then be uninsured and had not had enough access to medical services.

Risk adjustment solutions equalize the playing field to make sure that one adequately compensates healthcare providers for taking on high-risk patients. This improves access to health care for all people. One also pays Providers adequately paid for their accurate information about their patients’ health conditions and plans for treatment. Furthermore, the fully capitated Medicare Advantage model pushes both payers and providers to deliver the greatest preventive and appropriate treatment to their patients.

The process of risk adjustment is also applicable to the exchange for public health insurance and a few state Medicaid programs.

How Does Risk Adjustment Work?

Gathering information, including patient demographics, diagnoses, and professional encounter data, is the first step in risk management. Then one utilizes the information to assign each participant within the plan an assessment of risk.

One can determine risk scores by the severity of members’ chronic medical conditions as well as the additional Medicare-approved treatments they require. One can divide Medical diagnoses into groups of conditions with similar cost patterns, for example, the complications of diabetes, diabetes that does not have problems, MS, and congenital anomalies. People refer to this as Hierarchical Conditions Categories (HCCs).

All chronic illnesses are linked to an HCC. A patient who is seriously ill may be a part of several HCCs.

Healthcare providers must document or document each patient’s current health condition annually by using relevant codes from the lists of the International Classification of Diseases (ICD-10-CM). In addition to the ICD-10-CM codes, doctors must provide specific information in every health record to prove the presence of the disease and the treatment plan prescribed for it. If a diagnosis is not made even if it’s a chronic illness cannot be carried into the following year’s report.

In the process of risk adjustment, one assigns each HCCs a Risk Adjustment Factor (RAF). CMS employs RAFs to forecast ongoing healthcare expenses for the coming year, and to adjust capitated payments in the plan’s health insurance.

What are the key elements of a successful program to adjust risk?

Risk adjustment can only be dependent on the information that a health plan gets from health facilities and practices of the providers which take care of their members. But, the health insurance company is responsible for making sure that the information it receives is comprehensive and reliable. There are many steps a plan can take to improve the risk adjustment program it has in place:

Excellent outreach and communication:

Providers are healthcare professionals they are not data analysts. They should know what you require from them, and where their charts lack data, and where they could improve. Consistent and regular communication will help to improve the relationship between your providers. Providers can also benefit by reaching out to your patients to motivate them to attend their annual wellness appointments so that their health status is documented. In certain instances, it could be necessary to provide home-based tests.

A reliable medical record retrieval system:

When you work with a firm with a large medical record retrieval network you have a higher chance of getting the information that you require swiftly and efficiently. The presence of HIM specialists on the ground means that they are able to locate, analyze and access the data you require and expand the number of records you get without causing disruption to the providers. Ciox is available in more than 17,000 office locations of providers including both outpatient and inpatient settings. Additionally, Ciox has direct connections to the electronic medical records systems and can access medical records with minimal involvement.

The appropriate technologies:

Your risk adjustment program will benefit from a platform for data that has the capacity to store all of your information, extract and identify specific information from both structured and unstructured records, and run calculations. With the appropriate technology and data that you have, you can control data for specific populations, choose individuals to monitor, find individuals with a high risk of having serious health issues that are not documented as well as the absence of diagnoses, as well as automate the retrieval of records. The latest risk adjustment software allows you to finish your risk adjustment more efficiently as well as improve decision-making to aid in the mitigation of risk to revenue and to meet deadlines for submission with data that meets all CMS specifications. This includes Ciox’s 2LR tech.

Varun Shanbhag is a digital marketing professional and blogger with a strong passion for writing. He shares views and opinions on topics related to Indian festivals & a lot more.

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