The world of risk adjustment is tricky–but critical to ensuring payers are fairly compensated for covering patients who are more likely to incur high health care costs. With risk adjustment, government programs such as Medicare and Medicaid will adjust the revenue provided to a health plan/payer based on the health of those covered.

Specifically, in a risk adjustment model, an actuarial tool determines an estimate of how much it’s likely to cost to care for and/or cover patients based on their current and previous health history, demographics, and other relevant health factors.

Once an individual’s risk has been calculated, he or she is assigned a risk adjustment factor (RAF), or a score that is indicative of the member’s inherent risk for incurring higher medical expenses. Healthier, younger patients tend to have a lower RAF, while those who have chronic medical conditions or are older may have a higher RAF. It’s clear to see that the determination of a patient’s RAF is critical to the effectiveness and accuracy of these models.

How are RAFs determined?

Health conditions and diseases are categorized by either body system or disease process, resulting in a total of 79 Hierarchical Condition Categories known as HCCs. While there are numerous risk adjustment models out there, most use these HCCs–which are dependent on the 70,000+ ICD-10 diagnosis codes. Each HCC has an associated risk weight that helps to determine the RAF.

Risk adjustment chart review and HCC Coding

Since RAF scores rely on accurate ICD-10 codes, accurate risk adjustment coding is critical to any payer that participates in risk adjustment programs. While HCC coding is a model that works, it’s based on patient’s diagnoses instead of just the services provided to the patient–thereby making it significantly more complex. Because of this, HCC coding is heavily dependent on both provider documentation and complete and accurate coding. Inaccuracies at either end of the spectrum can result in costly errors that could result in serious risk adjustment charges from government payers.

Whether you’re a government payer or a risk-bearing provider, an effective risk adjustment coding (HCC coding) program can help ensure the accuracy of your RAF determination, and therefore has a significant impact on your bottom line. Real-time RAF reporting can help payers and providers alike understand how diagnoses affect the overall RAF score – and how to improve it with proper education and documentation.

Check and check again

To ensure accuracy and to avoid sizable penalties, payers can focus on improving HCC coding by performing ongoing risk adjustment chart reviews. Similarly, identifying opportunities to improve provider documentation through just-in-time training can be achieved with real-time RAF score reporting. These steps will help payers ensure they are appropriately compensated for insuring patients with complex medical needs.

At the same time, all organizations and payers are at risk for a government audit of their program, known as a Risk Adjustment Data Validation (RADV) audit. CMS conducts RADV audits randomly, or on a targeted basis for plans that have received a red flag for some reason (often due to a large increase in risk scores). The best way to prepare for such an audit is to be in a constant state of readiness. To do so, continuously review your performance through a regular audit process. By engaging an external outsource partner for specialized auditing, you’re likely to get an expert perspective as well as the benefit of technology tools and platforms that specifically provide valuable actionable data to use in ongoing performance improvement and educational efforts.


About GeBBS risk adjustment services
Getting the most out of shared risk programs requires a continued, expert focus on risk adjustment. This comes with an in-depth evaluation and understanding of your data–and an outside look is often the most effective way to truly get it right. Whether you’re a payer or other risk-bearing entity–GeBBS can help you maximize the impact of risk sharing programs for your organization. Our risk adjustment services provide an accurate, real-time look at your risk scores–based on a comprehensive and ongoing review of your data. With a proven service delivery model that takes chart review to the highest level, by ensuring timeliness, quality, accurate documentation, and optimal results. GeBBS’ end-to-end technology integrated solution maximizes risk score accuracy, HCC submissions, mitigates RADV risk, and enables health plans to ensure correct, compliant, and secure processes that deliver on desired ROI and overall financial performance. Services Include: medical record retrieval, risk adjustment chart review (for HCC coding), RAF score reporting, HEDIS® abstraction/workflow and solutions, quality review/auditing services, as well as provider education and support. To learn more, visit