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

Reinsurance and Risk Corridors

Reinsurance and Risk Corridors are two temporary programs also established by ACA.

  • Reinsurance is a transitional program established in each state to help stabilize premiums for individuals with higher cost needs who obtain insurance coverage during the first three years (2014 through 2016) of individual marketplace operation.
  • Risk Corridors are designed to protect against the uncertainty in rate setting during the first three years of the Marketplaces by creating a mechanism for sharing risk between the federal government and qualified health plan payers.

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