Risk Adjustment Models Overview Flashcards
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What is the primary purpose of risk adjustment models in the context of healthcare insurance?
Answer: To predict the health costs of individuals and populations to ensure fair payments to health plans for covering their members.
The fundamental purpose of risk adjustment is to use diagnosis codes and demographic data to predict healthcare costs, thereby adjusting payments to health plans to account for the varying health status of their enrollees. This ensures that plans covering sicker, higher-cost members receive adequate compensation and are not incentivized to avoid such individuals.
A coder is reviewing a chart for a 72-year-old patient enrolled in a Medicare Advantage plan. The documentation supports diagnoses of diabetes and congestive heart failure. Which risk adjustment model would primarily be used to calculate the risk score for this encounter?
Answer: CMS-HCC (Centers for Medicare & Medicaid Services - Hierarchical Condition Category)
The CMS-HCC model is specifically designed for the Medicare Advantage (Part C) population, which includes patients aged 65 and older and those with certain disabilities. The HHS-HCC model is for the commercial population under the ACA, and CDPS is often used for Medicaid.
Which of the following best describes a key difference between a prospective and a retrospective risk adjustment review?
Answer: Retrospective reviews focus on identifying and correcting documentation and coding issues from past encounters, while prospective reviews aim to address them at or before the point of care.
Retrospective reviews analyze documentation after care has been delivered and claims have often been submitted, looking back to find and correct errors. Prospective reviews are proactive, often involving pre-visit planning or point-of-care interventions to ensure accurate documentation and coding during the encounter itself.
The HHS-HCC risk adjustment model is considered a 'concurrent' model. What does this mean?
Answer: It uses diagnosis and demographic data from the current year to predict costs for the same year.
A concurrent model, like the HHS-HCC model, uses data from the current benefit year to determine payments and risk scores for that same year. This contrasts with a prospective model, like CMS-HCC, which uses data from a base year to predict costs for the following year.
Which of the following is a characteristic feature of the HHS-HCC model that is NOT present in the CMS-HCC model?
Answer: The inclusion of specific categories for infants and children, and the use of prescription drug categories (RxCs).
The HHS-HCC model is designed for the commercial ACA population, which includes all ages. Therefore, it has specific categories for adults, children, and infants. It also incorporates prescription drug data (RxCs) into its calculations, unlike the CMS-HCC model which primarily focuses on medical diagnoses for its payment model.
A risk adjustment coder identifies that a provider consistently fails to document the severity of malnutrition. This results in the assignment of a lower-weighted HCC and a lower risk score for these patients. What is the most appropriate action for the coder to take?
Answer: Communicate the documentation discrepancy to the provider and offer education on the specificity required for accurate risk adjustment coding.
A key role of a CRC is to identify and address documentation deficiencies. The appropriate step is to engage in provider education to improve the quality and specificity of the clinical documentation, ensuring it accurately reflects the patient's health status for proper coding and risk score calculation.