Medicare Risk Adjustment Services

Medicare Risk adjustment is an essential mechanism used in health insurance programs to account for the overall health and expected medical costs of each member enrolled in a health plan. The moto behind the medicare risk adjustment system is to adequately cover the expenses of offering covered benefits for Medicare Advantage enrollees, incorporating those with complex conditions.

How does Medicare Risk Adjustment work?

The Medicare risk adjustment system assigns a value or “risk score” to each beneficiary according to his or her age, gender, health status, and other factors. An individual beneficiary’s risk score in one year is based on diagnoses from the prior year. The agency makes periodic adjustments to the model based on analyses of costs for beneficiaries in the traditional Medicare program .These plans are approved and regulated by the Centers for Medicare & Medicaid Services (CMS) and the program undergoes an annual review process that makes policy changes and sets payment rates for the next year The MA risk adjustment model uses HCCs to assess the disease burden of its enrollees. Medicare Advantage plans have been using the Hierarchical Condition Category (HCC)/risk adjustment. HCC diagnostic groupings were created after examining claims data so that enrollees with similar disease processes. Accurate documentation of diagnoses by clinicians is a critical component of the risk adjustment process.

Our Capabilities Includes

  • Medical chart review and audit. Abstracting of missed and under -coded diagnosis based on office visit, hospitalization, lab works and imaging reports.

  • Implementation of ICD-10 Codes. Forwarding the missed diagnosis to the concerned provider after correlating with HCC codes

  • Minimize Errors, Maximize Accuracy. Cut down errors and improve precision in Raps Submission overall health and wellness

  • Analyze gaps in care. Analyze the Gaps in care and communicate to physician before patient checks in for next visit

  • Quality commitment. Demonstrate the provider’s commitment to quality care and improved patient outcomes

  • Medication reconciliation. Comparing the list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct information to the provider regarding medications.

HEDIS Software

Our team includes physicians and life sciences professionals extensive exposure to the below mentioned processes / projects for any large IPA/MSO across all the states:

  • Availability of In-house Tools and Software for ensuring Process efficiency and accuracy

  • Workflow intervention is designed in a most effective and efficient way to impact HEDIS data and timely closure of Gaps

  • Pre-visit and Post-visit chart review is performed to ensure high quality