Risk adjustment models are no longer confined to predicting costs for Medicare Advantage beneficiaries. Now they are more prevalent and widely adopted in various alternative payment models for value-based outcomes.
To calculate a per member per month (PMPM) capitated payment in managed Medicare plans, CMS uses a model that captures Hierarchical Condition Codes (HCCs) and assigns a Risk Adjustment Factor (RAF) to each patient. Different payment methodologies also use that model, for instance:
- Fee-for-service reimbursement (FFS) to compensate Accountable Care Organizations (ACOs) for sicker patients
- Individual and small group markets on health insurance exchanges
- Cost and quality measures for value-based purchasing for hospitals and providers
As you see, the implications of risk adjustment are far reaching. Timely assessment and accurate coding of patient problem lists can make huge differences in revenue for payers and providers alike.
Here are 5 steps that can improve clinical documentation at point of care leading to more accurate risk adjustment coding and more appropriate compensation for quality care.
1. Integrate clinical data… Read More »