Medicare Risk Adjustment and HCC Clinical Documentation Overview
- Author : The Coders Choice LLC
- Publisher : Unknown
- File Size : 10,5 Mb
- Release Date : 2019-03-09
- Genre: Uncategoriezed
- Pages : 102
- ISBN 10 : 1799242633
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Risk adjustment is a method to offset the cost of providing health insurance for individuals--such as those with chronic health conditions--who represent a relatively high risk to insurers. Under risk adjustment, an insurer who enrolls a greater-than-average number of high-risk individuals receives compensation to make up for extra costs associated with those enrollees.In the absence of risk adjustment policies, insurers have a financial incentive to deny coverage to higher risk individuals, and to write exclusions into policies or impose unaffordable premiums for individuals with pre-existing medical conditions. Risk adjustment aims to make comprehensive insurance available to all individuals, regardless of risk, and to allow plans that insure sicker-than-average populations to charge similar average premiums as plans that insure relatively healthy populations.The risk adjustment model enacted under the Affordable Care Act (ACA, or "Obamacare") is budget neutral. Total payments to insurers do not increase. Rather, insurers covering a relatively greater number of healthy individuals must contribute to a risk adjustment pool that funds additional payments to those insurers covering a larger portion of high-risk individuals.Risk adjustment models typically use an individual's demographic data (age, sex, etc.) and diagnoses to determine a risk score. The risk score is a relative measure of the probable costs to insure the individual. To cite a simple example, an individual with diabetes will have a higher risk score (his or her predicted healthcare costs will be greater) than an otherwise statistically identical individual without diabetes. Older individuals typically have a higher risk score than younger individuals, and those individuals with a personal or family history of certain conditions may garner a higher risk score than individuals without such a history.There are several risk adjustment models. The Centers for Medicare & Medicaid Service (CMS) risk adjustmen