Risk Adjustment

Risk Adjustment levels the playing field by discouraging adverse selection of members through a two-step process: Risk Assessment, which evaluates the health risk status of an individual to create a clinical profile; and Risk Adjustment, which determines the resource utilization needed to provide medical care to an individual.

Accurate Medical Records

Providers play a critical role in helping ensure the integrity of the data used in calculating overall health risk by providing:

  • Medical record documentation sufficient to support ICD-10-CM coding to the highest level of specificity for claim/encounter data submission and risk trends
  • Adherence to ICD-10-CM industry and reporting coding guidelines for conditions that are monitored, evaluated, assessed or treated (MEAT)
  • A comprehensive health status for each patient
  • Accurate, ICD-10-CM coding for every patient, every time

Helpful Industry Links

Read more about the new Risk Adjustment, Reinsurance and Risk Corridors standards in the Federal Register  .

Regulatory Overview/HHS Risk Adjustment Model

Clinical Documentation/Coding