Risk adjustment is a tool used to predict a health plan member’s future health care expenses based on existing data, including diagnoses and demographics.
Risk adjustment helps health plans calculate how much they should expect to pay towards each member based on their individual health needs. For example, a member with type 2 diabetes and high blood pressure may result in a higher CMS reimbursement to their health plan for health care services and associated costs than a member without those chronic conditions.
Risk adjustment is also used internally by health plans like Priority Health to:
- See a clear picture of our members’ health
- Improve quality of care with provider and member engagement using proactive measures
- Increase data submission accuracy and completeness to achieve more accurate risk factor scores
Who benefits from risk adjustment?
How are health risks calculated?
Chart reviews help everyone
Risk adjustment programs
More billing topics:
- ACA non-payment grace period
- Ambulatory surgery center billing
- Balance billing
- Clinical edits
- Check reissue procedure
- COB: Coordination of benefits
- Correcting claims
- Correcting overpayments & underpayments
- Diagnosis coding
- Dual-eligible members
- Front-end rejections
- Gender-specific services
- Medicaid billing
- NDC numbers on drug claims
- Office-based procedures billing
- Risk adjustment
- Unlisted codes, drugs & supplies