Risk adjustment is a method that government programs use to account for the risk profile of patients. A key element of risk adjustment is to ensure that the true health or illness burden and related risk of a patient is captured. Accuracy of a patient’s condition(s) is key to being compliant in risk adjustment.
The Affordable Care Act (ACA) established a risk adjustment program for all small group and Individual (commercial) members, regardless of whether they purchase coverage through an exchange. Medicare Advantage plans also include a risk adjustment program. The risk adjusment process for patients operates differently for commerical and Medicare members, but in general, much of the information required from providers and office staff is the same.
Providers play a critical role in helping to ensure the integrity of the data used in calculating the overall health risk of members by providing:
- A comprehensive health status for each patient
- Accurate and complete International Classification of Diseases (ICD) coding for every patient, every time
Medical record documentation that is accurate, complete and timely to support ICD coding to the highest level of specificity for claim submission
We are committed to improving quality of care through supporting the physician-patient relationship, and one way we do this is by encouraging our members to receive comprehensive annual health assessments that include identification of care opportunities and evaluation of disease burden.
Learn more about risk adjustment requirements and data validation audits in the Risk Adjustment section of the Administrative Manual.
Understanding your role in the process
Clinicians, administrators and office staff (e.g., medical coders and billers) all play unique and important roles in the risk adjustment process.
- Clinicians are responsible for documenting patient encounters in the medical record.
- Medical coders and office staff members are responsible for coding documentation in a member's medical record and submitting claims for encounters.
- Administrators are responsible for engaging the process to operationalize improvements for clinical documentation and coding, as well as managing audits.
Best practices
We conduct regular reviews of medical records to validate that the diagnosis codes reported are accurate and supported in the medical record. Patient diagnoses do not carry forward from one year to the next under the risk adjustment models, which means that all existing and chronic conditions must be evaluated and documented in the medical record at least once each calendar year for each patient, and the corresponding diagnosis codes must be reported via the claim for services.
Similarly, in any given year, we may be selected for a Risk Adjustment Data Validation (RADV) audit by CMS and/or the U.S. Department of Health and Human Services (HHS), which requires us to provide medical record documentation to validate diagnoses sent for risk adjustment.
During medical record reviews and RADV audits, we (or a third party we have contracted with to obtain medical records and perform a review) follow HIPAA guidelines 45 CFR 164.506(c)(4) while collecting and coding member information. It is not necessary for you to obtain a specific authorization from the patient to release these records. Your assistance and timely compliance with such requests enables us to meet our medical record review and collective RADV audit obligations.
Medical record reviews and audits underway
Commercial
- November 2023: We are requesting and reviewing medical records to support the diagnosis data we submit to HHS for dates of service in 2023. We have partnered with the vendors Advantmed and Episource LLC to assist us in the collection of medical records for this audit.
We have partnered with a team of providers who conduct comprehensive in-home and virtual health assessments to accurately assess and document a member’s current health status. During the assessment, the provider also observes and documents social determinants of health (SDoH). Our currently contracted vendors for these assessments are Signify Health and Advantmed.
Who qualifies for an assessment?
- All of our Medicare Advantage members are eligible.
- Members with the highest care needs are prioritized for outreach.
- In-person visits in rural areas may be more limited because of clinician availability.
- Members receiving hospice care are excluded from outreach but still qualify to receive the visit if they initiate the request.
What is included in the visit?
Signify Health and Advantmed will provide the following services to members during each in-home or virtual health assessment:
- Pain assessment
- Medication review
- SDoH assessment
- Fall risk assessment
- Family history review
- Depression screening
- Safety and functional review
- Cognitive impairment screening
- Review of preventive services history
Members may qualify to receive these ancillary tests as appropriate:
- Spirometry
- Bone density test (Signify Health only)
- Diabetic retinal eye exam
- Peripheral artery disease testing
- Colorectal cancer screening (FIT kit)
- Diabetes: Blood sugar control (HbA1c)
- Kidney health evaluation for patients with diabetes
What happens after the visit?
- Notes are provided to the member to remind them what care to follow-up on.
- A summary report is generated and sent to the member’s PCP.
- Any lab results are sent to the member and the PCP by mail.
- If concerns are identified during the visit, we receive urgent and non-urgent referrals to follow-up with members.
How to refer your patients
Contact Customer Service by calling the number on the back of the member’s ID card.
We recommend that providers and their staff become familiar with resources to learn more about coding and risk adjustment. Some resources that may be beneficial for you include: