Wednesday, October 24, 2012

Medicaid Risk Adjustment

By Susan McDonald

Numerous people all across the United States are currently using the Medicare Advantage plans that are offered through the Centers for Medicare and Medicaid services. The Centers for Medicare and Medicaid services have worked to develop the Medicaid risk adjustment model as a way of calculating and determining the quantity and number of payments to be presented to the plan's members or beneficiaries.

This model is used as a way to determine what the financial risk factor of each individual member is going to be through examining different aspects such as diagnostic data, age, and current health status and client history. The quantity of money that a client, or plan member, is likely to incur over one year is what represents their "risk factor". The method of risk adjustment is used throughout the health care field and insurance companies and is always being further developed and transitioned.

Since the foremost portion of Medicare risk adjustment is calculated based on claims reporting it puts a big significance on precise and careful reporting between the health care suppliers to the health insurance plan. When it comes to reporting client health care and claims information, there are a number of areas that can be cause for calculation mistakes causing improper risk adjustment. Much of the mistakes that have taken place are centered around the problems of recording client visits and activity as well as the sharing of information from supplier, health insurer and Medicare.

Since so much of the information gained from claims reporting is used to base the Medicare risk adjustment numbers off of the significance of correct claims reporting by the health insurance and health care suppliers is very high. Detailed and correct reporting will help to produce more correct numbers and decrease the quantity of mistakes. A number of mistakes that usually occur with this model are due to the reporting done during client interactions and visits as well as the level of communication between health care suppliers, insurance companies and CMS.

Health care suppliers and private health insurance plans will need to pay closer attention to the recording of each client encounter and application of the necessary diagnostic codes. This is how they will ensure proper risk adjustment for each individual client.

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