Risk adjustment

An HCC is a category of chronic medical conditions that share similar cost patterns. Learn more. Read more HCC FAQs here.

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Risk adjustment programs under the Affordable Care Act, Medicare, Medicaid, and Medicare Advantage evaluate patients’ risk scores based on a combination of condition and demographics data. Using claims, charts, eligibility, and other data, the United States Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) calculate how much to pay insurers based on the health needs of their member population.

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In this white paper, we will explore the challenges and progress of EHR interoperability and how to leverage AI capabilities to improve operational, clinical, and financial outcomes.

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MAOs have six additional months to ensure a complete and accurate data submission. See how to optimize your additional PY2020 Reconciliation Run.

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Major submission deadlines for Medicare Advantage (MA) and Affordable Care Act (ACA) risk adjustment programs are in the rearview mirror. We’re now entering a critical point in the annual risk adjustment activity cycle: The period where programs review and select new vendors ahead of the next high-intensity coding season.

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Risk adjustment is a complex but vital competency accountable care organizations (ACOs) must develop in order to succeed in CMS’s Medicare Shared Savings Program (MSSP). Without capturing a complete, accurate picture of member risk during the reporting year, ACOs risk jeopardizing their benchmark performance and care management effectiveness. However, many ACOs don’t have the internal expertise to implement a successful risk adjustment program.

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As patients, we’ve all felt the pain of trying to transfer medical records. Between the HIPAA release forms, wait times, forgotten requests, and antiquated transfer methods (faxes and CDs are still common methods in healthcare), the process of trying to give a new provider our health data is filled with friction and blindspots. This friction exists between organizations inside the healthcare system as well. Insurance plans struggle to obtain clinical data from providers, providers struggle to access plans’ more extensive member claims data, and healthcare vendors struggle to access data from both sides, even with the appropriate agreements in place.

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Discover how Datavant's AI solutions help healthcare organizations achieve the Triple Aim of improving patient experience, enhancing population health, and reducing costs in value-based care.

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