What Is Risk Adjustment in Simple Terms?

The term ‘risk adjustment’ in the healthcare field refers to the process of calculating payments to healthcare providers based on the conditions of their patients and their current and anticipated future healthcare needs. This procedure equates patient health status to a number that is commonly referred to as a ‘risk score.’ 

This number helps healthcare providers and payers predict future patient treatment costs. Healthcare insurance programs like Medicare use the risk-adjustment procedure to ensure that participants in their plan, including physicians, are reimbursed appropriately and accurately.


Why Is Risk Adjustment Important?

Risk adjustment is an important part of providing healthcare services. Most healthcare providers and payers have invested heavily in technologies that help them ensure risk adjustment is done correctly.

This is why more advanced risk adjustment software and platforms such as those offered by Infrescience continue to emerge. Inferscience has reliable risk adjustment solutions that will help you do HCC coding and get reimbursed for your hard work.

Patients receive better care and providers receive more equitable compensation under the risk-adjustment system. For instance, medical insurance plans can offer high-risk patients complimentary workout program memberships and assign case managers for specific diseases. This means that your patients will also be more engaged with their health because they have the necessary support. 

When your patient’s health status is combined with other demographic factors and wellness considerations, it’s easier to figure out the most effective action plan for comprehensive treatment. As a provider, risk adjustment enables you to do accurate reporting of your patient’s condition and recommend an appropriate treatment plan.

Risk adjustment improves medical reporting, making patients more aware of their conditions and healthcare options, which increases their engagement with their healthcare providers.


How Does Risk Adjustment Work?

Many coders are aware of the fee-for-service payment systems that help medical insurance companies reimburse healthcare facilities and physicians based on the services provided. Risk adjustment, on the other hand, enables medical insurance plans like Medicare Advantage and insurance companies to identify the health programs that are in high demand and the specific patients that need them through the diagnosis codes provided by their healthcare providers when submitting payment claims.

The main risk factors used in risk adjustment include the patient’s age, gender, medical history, geographical location, disability status, original Medicare entitlement, and any diagnosis of acute, stable, or chronic medical conditions that have been consistently documented. Along with these factors, medical insurance programs rely on HCC coding to determine and assign patients the appropriate risk adjustment factor scores. For this reason, it is imperative that medical coders follow proper coding procedures to avoid costly errors.  

Risk adjustment starts with you, as a healthcare provider, submitting your payment claims to the relevant medical insurance program or company with all the necessary diagnosis codes. These codes are derived from patient evaluations, so you must do a comprehensive evaluation of each patient.

Insurance programs then use these codes to determine the patient’s risk score. This score enables the insurer to determine the appropriate risk-adjusted payments and reimbursements.


Final Thoughts

The Center for Medicare Service uses risk adjustment to adjust reimbursements and payments to Medicare program beneficiaries as well as commercial insurance recipients. This way, it can make appropriate payments to enrollees with diverse anticipated medical costs.

As mentioned above, you must submit the correct diagnosis codes to help Medicare adjust its payments accordingly. Fortunately, you can rely on Inferscience’s solutions for efficient HCC coding–reach out today for a complimentary demonstration!





Click to rate this post!
[Total: 0 Average: 0]