7 Frequently Asked Questions About Medicare Risk Adjustments

The medical field is one of the exponentially growing sectors.  The improved technology used in the health facilities has greatly impacted the performance of this sector. Not only is the technology used in the medical equipment but is also used in the coding and billing processes. As you may know, the conditions of patients differ; some have a higher risk compared to others. Taking a step back, it was quite costly and challenging for the high-risk patients to access quality medical services, but today, with the risk adjustment models, it has become easier for them to access them at reasonable costs.

Below are a few frequently asked questions about risk adjustment;

1.    What is Medicare risk adjustment?

Medicare risk adjustment refers to a model that accounts or gauges the differences in the expected costs of a health care plan member who is at a higher risk, and in most cases, need intense medical treatment. Risk adjustment is vital as it helps both the facility and the insurer in forecasting any future medical needs of the patient.

2.    What is RAF?

Risk adjustment factor, RAF is a score metric used for every member, which generally is used to show their health status and is also used for billing to calculate payment. The RAF score is calculated based on a lot of factors including, the health condition in regard to the risk, age, gender, how long the patient has been in the institution etc.

3.    What is HCC?

Hierarchical condition category, commonly known as HCC, refers to a Medicare risk adjustment model of coding that insurance companies use to calculate risk scores and forecasts future medical costs for Medicare plan enrollees.  Conditions such as diabetes, chronic diseases, among others are the ones that are noted in medical coding. 

4.    How is HCC calculated?

As the name suggests, hierarchical condition category coding involves grouping diagnosis into hierarchies before calculating the risk scores and predicting future beneficiary costs. First, it begins by classifying diagnosis in DRG (Diagnostic related groups) that represent a set of medical conditions; then the DRG are further classified into CC (Condition categories) which stand for an extensive collection of similar medical conditions. The CC’s are clinically related with reference to costs. 

6.    What are the benefits of Medicare risk adjustment for patients?

Risk adjustment is really important to patients, especially the higher risk patients as they are able to access and afford health insurance. They, in turn, are able to get the right treatment and be part of the intervention and management programs. 

7.    What is the importance of Medicare risk adjustment?

Risk adjustment is vital as it caters for patients across the board. It ensures that the rates are quite affordable for the high-risk patients and that they access the right medical treatment at a relatively cheaper cost as opposed to what they would be changed if there was no risk adjustment plan. Also, risk adjustment models are often used to forecast any future expenses related to a high-risk patient and are quality tools for reporting and monitoring.