Monday, November 19, 2012

Medicare And Risk Adjustment

By Wendy Wright

The Centers for Medicare and Medicaid have created and put into effect a risk adjustment program that is used to help determine the quantity of payments to be given to members using the Medicare Advantage plan. Medicare Advantage utilizes a formula that takes into account various diagnostic data and client history in order to calculate the risk factors of a member. When put into simple terms, this risk adjustment formula takes the client's health concerns and puts a price tag on how much each issue will likely cost the private health care plan over a period of time. Risk adjustment has been used within Medicare and Medicaid for a long period of time and is continually being bettered and researched.

One of the most important parts of a productive Medicare risk adjustment is being able to correctly predict the care costs of a client connected to a particular disease. Currently Medicare gets its information from the client's health plan in the form of claims data as the method for determining the payment for risk adjustment. This means that from the data gathered through the information given to Medicare by private health insurance companies is the foremost source of determining how much payment these private plans should receive to cover their member's likely health care costs.

Since there is so much information provided by private health insurance companies it is necessary to pay close attention to the accuracy of the information reported through the health care suppliers as well as the health insurance providers. Unfortunately there is a large chance for errors in data reporting and these mistakes can end up in incorrect Medicare payment amounts. Many of the areas that have a potential for incorrect reporting are the recording of the member's visits as well as other health activity and the sharing of this information from the health care supplier, insurance companies and the centers for Medicare and Medicaid.

A common mistake that has been found is not completely listing all of the applicable diagnostic codes to a specific patient who is suffering from multiple health conditions. If codes are not applied to patient's charts then they will also not be compensated through the Medicare program. Proper recording of patient encounters and paying attention to detail in patient health issues and concerns is essential in proper risk adjustment calculations.

To know more about Medicare risk adjustment go to Altegra Health.

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