Retrospective Risk Adjustment

There are been more importance being placed on the role that risk adjustment needs to play within the health care industry. This is especially true when it comes to how the Centers of Medicare and Medicaid Services distribute funds for plan members, especially members of the Medicare Advantage plans. The goal of risk adjustment is to properly calculate just how much an individual is likely to cost in health care services over the span of a year. Through the use of risk adjustment, private health plan providers who service those eligible for the Medicare Advantage plan are compensated for some of the costs of their plans enrollees.

One of the reasons for the increased amount of focus on risk adjustment methods as well as outcomes is the need to lower the costs of the health care industry. Risk adjustment is used to determine the amount each patient or member, and their health care provider, will receive from the Medicare Advantage plans. Risk adjustment focuses on the coding of a patients chart, and analyzing the codes applied and determining a monetary value from these codes. However, if the codes are not correct, or there are a number of diagnostic codes missing for an individual then the calculation will likely be far too low, causing excessive costs.

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 important to make sure that none are being missed or overlooked. Health care companies 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.

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 important 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 about Retrospective Risk Adjustment go to Altegra Health.

Go to Altegra Health to know more about Retrospective Risk Adjustment.

Risk Adjustment Analytics

There are a number of positive outcomes of risk adjustment and many believe some of them will include increased cost savings for health care providers and insurance companies as well as a better distribution of funds. The healthcare system as it is working today has a number of issues that we are trying to solve and improve upon, many professionals believe that through the use of risk adjustment, some of these issues can be improved. Within the health care industry, the improvement of the types of solutions put in place for risk adjustment are being focused on and updated.

Risk adjustment is often used in the health care field as a way to calculate the amount of money a patient is likely to cost in relation to their health issues and care as well as other factors. It is through the evaluation and analysis of this information that allows health insurance companies as well as the centers for Medicare and Medicaid to calculate the possible costs for the care of an individual over one year. There are still a number of areas that can be improved within risk adjustment, and over the past years, there have been a number of improvements already made.

One of the most important factors within the area of risk adjustment is being able to accurately estimate the costs of an individual by looking at their different factors, issues and other potential risks. One of the issues within the area of risk adjustment is being able to create a type of software that will be capable of properly assessing the patients information and providing a qualified assessment of the potential risks and overall cost estimations. A number of different health care companies will provide a type of risk adjustment software to complete these calculations, however there are still much needed improvements to be made to ensure accuracy.

Focusing on the individual, and their specific issues, potential risks and other factors that add into the estimated yearly costs is one of the most important factors of risk adjustment. One of the areas that is being focused on within risk adjustment is the creation of a software that will be capable of completing accurate calculations of the overall financial risk of a particular individual or patient based on the factors presented. Currently there are many different health care companies that provide risk adjustment software, however there are still a number of improvements that can be made to this type of analytics.

To learn more about Risk adjustment go to Altegra Health.

To know more about Risk Adjustment go to Altegra Health.

What Is Risk Adjustment Data Validation?

The payment model for 2011 will be released by the Centers for Medicare and Medicaid services and expectations are that there will be an increase in the risk adjustment data validation, also known as RADV. It is this risk adjustment data validation that is used in order to create the calculation of payment error for a number of Medicare or Medicaid beneficiaries. There have been reports made that the overpayment recoveries that are scheduled for the year 2011 will be increased by the centers for Medicare and Medicaid.

Every member who is a part of a Medicare or Medicaid sponsored plan is provided with diagnostic codes found in the Hierarchical Condition category as a way to categorize the members of a plan. Every category, or code, is representative of a specific illness of disease and is also linked with a monetary value of the cost to care for this type of illness. Each code that is assigned to a patient becomes the specific dollar amount that their insurance company receives for compensation of covering the patient with that illness.

The purpose of the risk adjustment data validation is to be able to check for the correct and accurate coding of these patients and their charts. It allows the centers for Medicare and Medicaid to ensure that the care the patient has received or is in need of matches the codes assigned to them. Through the centers of Medicare and Medicaid services audits will be completed as a way to ensure that the information coded matches the actual health of the patient or member. In the case that the audit does not match the information provided by the health insurance company, the difference in the overpayment made to the insurance company by the centers for Medicare and Medicaid services will be returned to them.

The past year was the first time that this new auditing system was put in place by CMS. It is hoped that this program will be a good start in a mission to gain back some of the overpayments that have been made by the centers of Medicare and Medicaid services through a number of different programs. The centers of Medicare and Medicaid services are estimating that potentially over 300 million dollars’ worth of overpayments may be collected through the RADV program. This program can be a positive factor on ways to help improve our health care system and the rising costs that the public is faced with on a day to day basis.

To know more about Risk Adjustment Data Validation go to Altegra Health.

Go to Altegra Health to know more about Risk Adjustment Data Validation.

HEDIS And Quality Measure Analytics & Abstractions

The healthcare effectiveness data and information set, also known as HEDIS is something that is used in many different health care plans across the United States. It is a method used to evaluate many different areas of performance measures. The healthcare effectiveness data and information set is utilized as a way to specify the quality of service and care provided within a health insurance company and a health care plan. The measurements created by HEDIS are made up of 76 different standards that span across a number of different care situations.

HEDIS has a number of benefits, one of them being how specific the individual measurements are, which allow for an easy comparison with other plans. The goal of the system is to be able to allow individuals the chance to compare a number of different health care plans which offer different benefits in an easy way. This is just one of the benefits that utilizing the HEDIS system as a measurement tool can bring. The system can be utilized by a number of different organizations and companies as a way to find errors in the current system, and how best to improve upon these areas of weakness.

One of the ways that HEDIS is used is to determine the right health care plan from the perspective of the purchaser, or potential member. HEDIS is also used by the health insurance companies as a way to find out what aspects are missing from their health care plans. Health insurance companies are able to utilize this information in creating health care plans that are better suited for their potential members as well as provide higher quality of service.

The way that the measurements are conducted and the systems used to qualify the data through HEDIS are constantly being developed and improved. Every year adjustments are made to the measurement systems through a process to keep content effective and current that is developed through NCQA.

The areas are important to consider for many individuals looking to find a health care plan to cover their needs. There are a number of different issues that are looked at when going through the HEDIS system, some of the common ones include childhood immunizations, medication management, BMI assessments, diabetes care, asthma medication and the controlling of high blood pressure.

Go to Altegra Health to know more about Hedis and Quality Measure Analytics & Abstractions.

Encounter Data

Health insurance companies use a number of different factors when considering and making the appropriate cost decisions on health plan premiums. On a year to year basis, each individual health care plan is looked at and it is decided whether or not the premium for that plan stays at the same amount, is lowered, or is raised. While there are a number of different factors to consider, one of the main aspects that is looked at by health insurance companies is the encounter data for that particular patient or client.

The information that is collected about a patient, or a group of patients, and the services that they have received from health care providers is what encounter data is comprised of. There are a number of aspects within this that are looked at more deeply. Encounter data will include, when and where the services were provided as well as who provided the services, and who the services were provided to. The use of encounter data can vary, but in many cases it is used as a way to help to develop a cost profile of a group of clients, or an individual. This is one of the main factors looked at when a health insurance company is trying to determine if a raise in premium costs for a group is necessary or warranted.

Encounter data centers around a group of core questions about the services provided. It considers the when, what, where, who and how much of the interaction between patient and health care providers. As well as detailing the services rendered, it also includes, descriptions, dates and costs of each different and specific service.

Since the health care reform initiative began, and the Affordable Care Act was established, more emphasis has been placed on the importance of encounter data and the collection and use of the information. Many states have begun to initiate sanctions about the collection of encounter data, while others are offering incentives for higher quality collection and analyzing of the data. Many people believe that the collection and use of encounter data is a good way to determine where cost savings can be best found within the growing expenses of our health care system. When encounter data is collected incorrectly it could lead to higher costs than what was projected which could increase premiums or the cost for health insurance.

Encounter data is one of the most primary forms of service records for patients and health care providers. It is a record of the services that they have received, and when not executed correctly can provide information that leads to higher, or much lower estimations of yearly health care costs. In many cases it has been found that a lack of correct and accurate encounter data will lead to a possible increase of health care costs. In other cases, the incorrectly, or not collected, encounter data translates to a risk adjustment that is too little, and then costs the health plan provider excess funds to make up the difference. Many states are beginning to enforce more accurate encounter Data collection, and others are offering incentives for providing more of this data.

Go to Altegra Health to know more about Encounter Data.