About risk adjustment

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What is Risk Adjusted Reimbursement?

Risk adjustment is a process of collecting all diagnosis codes from patient charts and using these illnesses (along with their comorbidities and complications) to determine the ICD-10 codes which drive risk . . . risk for the patient & risk of increased cost to take care of the patient. 

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The Purpose of Risk Adjustment

Ensures accurate and adequate payment based on expected medical costs. 

Promotes higher quality care through the identification of all the patients' singular risky conditions. 

Incorporates each member's health status reflecting costs associated with their health care needs.

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The Risk Score

Higher risk scores represent members with a greater than average burden of illness.

Lower risk scores represent a healthier population, but may also falsely indicate a healthier population due to:

1.  Inadequate or incomplete chart documentation.

2.  Incomplete or inaccurate diagnosis coding.