Exploring Risk Adjustment Solutions Across The Healthcare Spectrum

Risk adjustment models are designed to evaluate the risk scores of patients depending on their health conditions and demographics. It helps in systematically categorizing the health status and health spending of the enrollees included in the insurance plan. It also looks at their healthcare outcome, costs, and other essential factors. Using the right Risk Adjustment Solution is critical to ensure that the needs and health complexities of patients are fully captured and resources are allocated appropriately to deliver value-based care. The healthy patients are ranked with lower risk scores than the patients with high risk. Various public and private payers can estimate compensation based on the practice's overall risk factor by analyzing the health of a provider's patient population.

The Healthcare industry is moving towards value-based care, the categorical coding i.e HCC Coding is becoming incredibly crucial for providers. HCC coding aims at appropriately reimbursing the providers who provide quality care to patients with high risk.  However, payers and healthcare organizations rely on coding companies to perform accurate coding. Keeping track of thousands of codes isn’t an easy task. NLP technology and big data analytics can improve the productivity of coders.

Impact of Risk Adjustment Solutions on Providers

Health plans use Risk Adjustment Solution as a means of covering the expenses of their enrollees, and to discourage incentives to enroll healthier individuals. Risk adjustment is responsible for providing funding to health plans. In return, the healthcare entities take appropriate care of the enrollees with different health conditions. To provide enrollees with better care and to make providers operate efficiently healthcare plans need proper funding. If the health plans receive enough funding they can offer many perks to the providers in terms of financial incentives contractual terms, and development of programs for the improvement of health outcomes.

It is important for providers to understand the fundamentals of risk adjustment and how it affects the healthcare system. Since risk adjustment is based on diagnosis coding, it is critical that all chronic diseases be reported at least once a year in a face-to-face interaction. So if the physician receives a monthly capitated payment, all diagnoses should be classified with the utmost level of precision, and all interactions should be reported to the health plan.

To protect yourself against audits and potential fraud, become familiar with standard coding rules for your specialty and ensure that all reported diagnostic codes are fully supported in the medical record.