What is risk adjustment, and how does it work? 

Risk adjustment equates a person's health status to a number, known as a risk score or risk adjustment factor (RAF), to predict costs. This helps to ensure providers are paid fairly for treating patients with complex medical needs. 

Each year, a patient’s risk score is assigned based on demographics and dianogses using Hierarchical Condition Category (HCC) coding. HCCs are a list of diagnoses given a value for risk adjustment purposes and updated annually by the Department of Health and Human Services (HHS). It's important to note risk scores are calculated by the state or government entity that oversees the risk adjustment program.

 

Measuring a patient’s demographics and health status 

A patient’s demographic information is obtained through the enrollment process. Whether applying for Medicare, Medicaid, or other insurance, a patient submits certain personal data as part of the process, which is used to establish program eligibility and coverage.

When determining risk adjustment, a variety of demographic factors are used to calculate a risk score, including: 

To submit claims for patients, it's essential to accurately capture all conditions affecting their health status yearly to calculate their risk score. Failure to recapture a chronic illness from a previous year could cause a decrease in the patient's risk score for the current year while reporting additional conditions will increase the score. It's vital to capture diagnosis codes correctly. 

In addition, it’s important to note that not all diagnosis codes are used in HCC risk score calculation. Only conditions that are costly to manage from a medical or prescription drug treatment perspective will likely be in HCC coding.

 

How you can improve the quality of care with risk adjustment services

Risk management services can provide fairness in healthcare payment systems and enhance the quality of care for patients.

Some of the risk adjustment services available include:

 

Why outsourcing risk adjustment services benefits companies 

Working with a healthcare partner for risk adjustment can help you streamline operations, reduce costs, and improve the quality of care.

Some of these benefits include: 

 

Our risk adjustment services

ADEC Healthcare offers risk adjustment services that can improve the accuracy of your risk adjustment data and comply with regulatory requirements.

Our services include:

 

RISK ADJUSTMENT

1. Introduction 

2. What is risk adjustment as it relates to healthcare? 

3. What are general risk adjustment services? 

1. HCC Coding: Hierarchical Condition Category (HCC) coding is a risk adjustment model used by Medicare and other payers to adjust payments based on the health status of a patient. HCC coding services involve identifying all relevant diagnosis codes that can impact patient risk scores and ensuring that those codes are accurately recorded and reported.

2. Documentation Review: A thorough review of medical records can identify missing or incomplete documentation, leading to inaccurate risk scores. Risk adjustment service providers can conduct a documentation review to ensure all necessary information is captured and reported correctly.

3. Provider Education: Providers may benefit from training and education on risk adjustment best practices to ensure documentation and coding are accurate and complete. Risk adjustment service providers can offer training to providers to improve coding accuracy and reduce potential errors.

4. Risk Assessment: Risk adjustment service providers may offer risk assessment services to identify potential gaps in care, improve patient outcomes, and capture all necessary data for accurate reporting.

5. Analytics and Reporting: Providers and payers may benefit from advanced analytics and reporting to track performance metrics, identify areas for improvement, and measure the effectiveness of risk adjustment efforts. Risk adjustment service providers can offer analytical tools and reporting capabilities to support these needs.

6. Compliance and Audit Support: Risk adjustment service providers may also offer support for regulatory compliance and audit readiness, helping providers and payers prepare for audits and mitigate risks associated with non-compliance.

4. Why outsourcing risk adjustment services benefits companies 

1. Allows companies to focus on their core services while others take care of support

2. Ensures compliance and accountability 

5. Our risk adjustment services

1. Cost project for next year

2. HCC coding 

3. First or second pass