Risk Adjustments
Risk adjustment is an actuarial tool used to calibrate payment to health plans or other stakeholders based on the relative health of the at-risk population. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of a member. Risk scores measure members’ relative risk and risk scores are used to adjust payment for each member’s expected expenditures.
Risk Adjustment Best Practice
See each member at least once each year and complete an Annual Wellness Assessment (face-to-face visit). Health Plans have their specific forms and typically pays provider to complete the comprehensive assessment. Preferred IPA has a generic Annual Wellness Assessment form
Evaluate and document all chronic conditions and historical amputation(s) in the medical record, code all diagnosis using ICD-10-CM codes, and submit all diagnosis to Preferred IPA.
Coding: Providers need to link the chronic conditions to yield higher RAF scores in charts (linking conditions to medications and document manifestation of a condition: amputation due to poor control of diabetes).
Accurate Document
Condition Assessment: Stable, improved, tolerating meds, deteriorating, uncontrolled.
Example Conditions/Diseases: Chronic Kidney Disease, Cancer, Diabetes & associated manifestations, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Morbid Obesity, Major Depression, Cardiovascular Disease, etc.
Care Plan: Monitor, D/C Meds, continue current meds, refuses treatment, refer to specialist.
Acceptable Source Data: IP, OP and Physician Office Visits (Face-to-Face)
Exclude Data Source: SNF, Hospice, Nursing Homes, Lab, Radiology, Ambulance, DME, Ambulatory Surgery Centers.
References: Anthem Blue Cross
Introduction to Risk Adjustment, Documentation & Coding Best Practices