Effective Risk Adjustment Strategies for Success in Healthcare

  • Written by Ashley Mark
  • Thursday 4th May 2023
Effective Risk Adjustment Strategies for Success in Healthcare VLMS Healthcare

Providers under value-based care are reimbursed for quality care, not more care. Patients suffering from critical conditions need more sensitive care than patients who are usually healthy. Risk adjustment is a vital component of medical billing that focuses on maintaining that health plans and providers get appropriate payment for the sake of services they have rendered to the patients. 

Gathering full-fledged demographic and diagnostic data for each patient through proper HCC risk adjustment coding is highly effective in value-based care models. This is where the support of skilled and professional medical billing and coding companies can be great companions for physicians.

Why is risk adjustment important?

The switch from fee-for-service to value-based care is transforming how patients are cared for and how providers are compensated for performance. Risk adjustment is essential for health plans and patients delivering care for high-risk patients.

The fluctuations in the health condition of patients can essentially affect the cost of providing care. For example, patients with severe diabetes or heart disease need more sensitive care and treatment. Risk adjustment judges each patient’s health condition, medical history, and other factors to determine the estimated cost of care for a particular patient. This proves risk adjustment is critical for both health plans and providers:

  • Risk adjustment is important to ensure the proper compensation to health insurance plans. With this, they can manage coverage and easily access care for beneficiaries.
  • Risk adjustment guarantees that physicians get fair and deserved reimbursement for the high-quality care rendered to patients with complex health needs. This is managed by considering the payment rates for healthcare services on the basis of differences in the health status of patients. 

How can physicians benefit from risk adjustment?

  •  Correct HCC coding

Error-free HCC coding is critical to highlight patient complexity and frame the scenario of the whole patient for risk adjustment. This way, they can obtain the proper reimbursement for serving critical patients. Providers should keep active diagnoses, including chronic conditions, annually.

  • Quality clinical documentation

Physicians should keep a track record of complete and accurate documentation of patient conditions. This helps in supporting both risk adjustment and quality reporting initiatives. All necessary clinical data should be clearly stated, including diagnoses, medical history,  and treatment plans. Sorted documentation is critical to accurately collect a patient’s proper status of disease severity or risk using HCC codes. It also ensures that the services provided are appropriately reimbursed.

The most vital element of HCC coding is assessing health record documentation to gain reportable conditions and assigning the correct ICD-10 codes to reflect them. Risk adjustment documentation best practices suggested by AHIMA include:

  • Documenting all related circumstances and relationships.
  • Document diagnoses as the history of or past medical history until they no longer exist and are resolved.
  • Clearly stating complications or risks of a disease process.
  • Consider all current diagnoses as part of the current medical decision-making process and document them in the note for every visit.
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