To determine the amount of payments given to members enrolled in Medicare Advantage plans, The Centers for Medicare and Medicaid have created and put into effect a risk adjustment program. The formula utilizes diagnostic data and patient history, from this the risk factors of a member will be calculated. Simply put, the risk adjustment formula considers the patients health issues and puts a price tag on how much is will likely cost the private health plan to care for the individual over a period of time. Constantly being improved and researched, the risk adjustment formula has been used by Medicare and Medicaid for a long time.
Connecting a patient to a disease and correctly predicting the care cost of the disease successfully is one of the most important parts of the Medicare risk adjustment formula. The patient's health plan is the source for the information that Medicare gets in the form of claims data, determining the risk adjustment. This means that the data given to Medicare by private health insurance companies is the main consideration for how much these companies will receive to cover the likely health care costs of its members.
Since the main portion of Medicare risk adjustment is calculated based on claims reporting it puts a large importance on precise and careful reporting between the health care providers to the health insurance plan. When it comes to reporting patient health care and claims information, there are a number of areas that can be cause for calculation errors causing improper risk adjustment. Much of the errors that have taken place are centered around the problems of recording patient visits and activity as well as the sharing of information from provider, health insurer and Medicare.
Limiting the number of diagnostic codes is one error that is commonly made. Some patients will be documented to have a certain number of diagnostic codes when there are many more codes that apply to the patients health and situation that are not being reported. Close attention to recording and documentation will be needed in order to get a correct risk adjustment for each patient.
Altegra Health is a leader in the industry of risk adjustment. Getting health care providers and health insurance plans the proper reimbursement are Altegra Health's main focus.
Connecting a patient to a disease and correctly predicting the care cost of the disease successfully is one of the most important parts of the Medicare risk adjustment formula. The patient's health plan is the source for the information that Medicare gets in the form of claims data, determining the risk adjustment. This means that the data given to Medicare by private health insurance companies is the main consideration for how much these companies will receive to cover the likely health care costs of its members.
Since the main portion of Medicare risk adjustment is calculated based on claims reporting it puts a large importance on precise and careful reporting between the health care providers to the health insurance plan. When it comes to reporting patient health care and claims information, there are a number of areas that can be cause for calculation errors causing improper risk adjustment. Much of the errors that have taken place are centered around the problems of recording patient visits and activity as well as the sharing of information from provider, health insurer and Medicare.
Limiting the number of diagnostic codes is one error that is commonly made. Some patients will be documented to have a certain number of diagnostic codes when there are many more codes that apply to the patients health and situation that are not being reported. Close attention to recording and documentation will be needed in order to get a correct risk adjustment for each patient.
Altegra Health is a leader in the industry of risk adjustment. Getting health care providers and health insurance plans the proper reimbursement are Altegra Health's main focus.
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