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.