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