Risk Adjustment
Risk Adjustment calculates a relative risk score, which can be accumulated to compare the health risk of a population of individuals. Johns Hopkins Health Plans uses Risk Adjustment for its Medicare Advantage plan, Advantage MD.
The Risk Adjustment process is regulated by Centers for Medicare and Medicaid Services (CMS). The CMS Risk Adjustment model measures the burden of diseases, which includes Hierarchical Condition of Categories (HCC), which are linked to ICD-10 diagnosis codes.
HCC coding is prospective in nature. Diagnosis codes reported on claims determine a patient’s disease burden and risk score. Reporting the appropriate diagnosis code(s) and complete clinical documentation by the provider ensures the accuracy of the member’s risk score. Furthermore, if not addressed, chronic conditions are likely to persist, leading to additional medical expenses.
The goal of any health plan is to have an accurate picture of the health status of their membership, which, according to CMS guidelines, must be captured annually. Health plans can support the best care for their members when they are informed about members’ health statuses and are aware of their conditions.
Johns Hopkins Health Plans Risk Adjustment department’s priority focus is to collaborate with all health care providers in support of HCC Risk Adjustment efforts.
There are various types of Risk Adjustment programs that are used by Johns Hopkins Health Plans to assist our providers:
- Whole Health Assessment (WHA)
- Chart Review/Retrieval
- Coding Documentation Improvement (CDI)
Johns Hopkins Health Plans Risk Adjustment Resources/Tools
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The goal of the program is to ensure providers indicate chronic conditions for Johns Hopkins Health Plans members. Providers should follow the instructions to submit a completed WHA form along with medical documentation in reference to the member visit.
Forms can be accessed and submitted in Availity throughout the calendar year. Providers are incentivized for which when completed.
If you have specific questions about the WHA, please email [email protected].
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A significant part of verifying diagnosis codes is supporting documentation. To improve accuracy and completeness, medical chart review and retrieval will allow Johns Hopkins Health Plans Risk Adjustment team a more complete picture of member health status for Centers for Medicare & Medicaid Services (CMS).
Johns Hopkins Health Plans, with Episource and Optum, may request a medical record/chart from the provider for members included in WHA and CDI.
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The Risk Adjustment team offers a training which covers:
- Basic coding guidelines
- Best practices to promote quality documentation
- Accurate coding
Areas the RA team will focus on:
- Documentation and coding
- Case study examples
- Broad overview of Risk Adjustment
Topics such as:
- HCC documentation and coding practices
- Trends to avoid
- Application of T.A.M.P.E.R. and specificity
- Commonly missed and miscoded diagnosis codes
Risk Adjustment FAQs
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Risk Adjustment provides more accurate payment from CMS based on the health status of the member — less for healthy members, more for sicker members.
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- Improve the overall health status of patients by ensuring patients are treated once a year for all chronic conditions.
- Improve care coordination for patients with select chronic conditions by ensuring all conditions are tracked by primary care and treated by the appropriate specialty.
- Improve population health capabilities by ensuring complete and accurate registries to be used in care management and disease management programs.
- Improve the accuracy of payments to providers through payer contracts by appropriately capturing disease burden of populations.
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- HCCs are sets of medical codes that are linked to specific clinical diagnoses.
- HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a Risk Adjustment model that identifies individuals with serious acute or chronic conditions.
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Yes. Review the historical diagnosis information, and document the current assessment and treatment plan.
If interested in any of these topics, including a specialized review from the Johns Hopkins Health Plans Risk Adjustment team, we can coordinate a review of medical records with a Certified Risk Adjustment Coder to go over CDI opportunities observed within the medical documentation.
Please email [email protected] and someone on our team will schedule time to answer any specific coding questions.