![]() ![]() Inaccurate or non-specific diagnoses can impact health care services, outcomes and reimbursement payment to the health plan for ongoing care of that patient.ĬMS’s Hierarchical Condition Category risk adjustment model assigns a risk score, also called the risk adjustment factor or RAF medical abbreviation “RAF score”, to each eligible Medicare Advantage beneficiary. Using HCC risk adjustment coding and Medicare risk adjustment software this encounter data is then used to predict health costs for the subsequent contract year for the health plan. ![]() Documentation in health risk assessments must indicate the provider’s health care services plan for patient help or Management, Evaluation, Assessment or Treatment (MEAT) of the condition. CMS Federal Government policy requires that a qualified healthcare provider describe all chronic conditions and severe diagnoses for every patient, every year, to establish a health profile. Some health risk assessments may not be predictive of ongoing expenses, but severe acute diseases and injuries or chronic conditions such as diabetes, heart failure, and chronic obstructive pulmonary disease may pose a continuing financial burden to the healthcare system.Īll risk adjustment models rely on comprehensive healthcare analytics, encounter data and evidence-based reporting of patient care. Not all encounter data like diagnosis codes will “risk adjust,” or map to an HCC in the Medicare risk adjustment model. Only those ICD codes that map to an HCC category are used in the risk adjustment processing system. HCCs are a grouping of clinically related diagnosis codes with similar associated cost to the healthcare system. For example, chronic medical conditions like a diabetes diagnoses, including complications, has a higher risk score and in turn greater anticipated Medicare Advantage risk and healthcare costs than diabetes without complications. Higher category risk scores represent higher anticipated healthcare costs for Medicare Advantage health plans. This method puts related encounter data like medical diagnoses into groupings based on resource use. The Centers for Medicare & Medicaid Service (CMS) risk adjustment model uses the Hierarchical Condition Category (HCC) method to calculate risk scores for Medicare Advantage beneficiaries. There are many different models and financial incentives for medical risk adjustment within the health and human services system. Medicare risk adjustment is also intended to encourage health plans to enroll accurately represented beneficiaries of all types, including high risk enrollees with chronic medical conditions and those who are likely to need more expensive care. Medicare risk adjustment is designed to ensure that Medicare pays health plans fairly, and that plans are not unfairly penalized for enrolling sicker beneficiaries. ![]() Medicare risk scores are calculated using a formula that takes into account many different factors, including age, sex, race, health status, and use of Medicare services. Medicare pays health plans based on the number of Medicare beneficiaries enrolled in the plan, and the risk scores of those beneficiaries. Medicare risk adjustment is a process that Medicare uses to pay health plans. ![]()
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