Risk Adjustment is a method of offsetting the high costs of health insurance for high-risk patients. So, the insurers who have enrolled a relatively higher number of more-than-average risk people and who are likely to face higher claims due to the high-risk profile of their insured people are assured payments by government. This is done by way of contributions by those insurers who cover relatively higher number of healthy individuals towards a risk adjustment pool. This is the model of risk adjustment adopted under Affordable Care Act. This Act is also known as Obamacare and this method makes risk adjustment a budget neutral process.

There are many models of risk adjustment. Hierarchical Condition Category (HCC) method is used by Centre for Medicare and Medicaid Service (CMS) for calculating the risk scores. HCC risk adjustment model ranks different types of diagnoses into categories that represent conditions with similar costing patterns. Under the model, one person can come under more than one HCC. Use of ICD10-CM codes is done for HCC coding purposes. All of these models of risk adjustment depend upon accurate reporting of data. Risk Adjustment Coding, therefore, assumes significance. Professionals certified in HCC Coding are required to perform the needful coding tasks.

How it works:

Step 1: Code First Healthcare’s Claims Validation services confirm the HCCs that are documented in a claim (administrative data) are supported by clinical documentation.

Step 2: Our solution considers claims data provided by the client and maps all the diagnostic codes to HCCs.

Step 3: Code First Healthcare will review and blind code a chart and match the clinical data back to the claims data.

Step 4: HCCs that are not supported are reported back to the client as unconfirmed.