The Year 2021 Brings New Trends Of Risk Adjustment Solution

The Year 2021 Brings New Trends Of Risk Adjustment Solution

Risk Adjustment solutions predict if the health cost of a particular patient or group of patients is more or less than the general population.

This prediction helps in adjusting the payments accordingly. Risk adjustment (RA) compensates both health plans and care providers for sicker patients. It also decreases their incentives for selecting healthier or cost-effective patients.

The Risk Adjustment model considers the health risk of recipients by using numerous health variables, including recipients’ demographic features, social determinants of health, and the diagnosis.

Medicare Advantage (MA), also known as Part C plans, is a part of the Medicare program for older people and disabled adults who qualify to receive social security. Private insurance companies offer MA Plans instead of the federal government. These plans demonstrate the benefits of the private sector’s innovative ideas for government-run Medicare Plans. The Centers for Medicare & Medicaid Services (CMS) is committed to reinforcing MA Plans by facilitating better innovation, accountability, adaptability, and functionality of health plans.

It is becoming necessary for healthcare providers to identify care gaps and ensure accurate payer-agnostic data to build a multi-payer system more patient-centric. It also requires checking risk adjustment scores,

patient outcomes, reimbursement.

and

clinicians’

coding

diagnoses

for

fair

Risk Score Calculations The risk scores are an integral element of RA solutions as they influence reimbursement. These scores are produced for each payment year from the final result of the CMS risk adjustment model. A significant reduction in risk scores means that health plans will not get funds equivalent to their projected expenses in the next year.

The Health Plans and CMS are concentrating on Telehealth-based diagnosis for risk score calculations. CMS will determine the 100 percent risk score using the 2020 CMS-HCC coding and diagnoses records from Encounter Data System and Fee-for-Service claims.

The 21st Century Cures Act & Interoperability Interoperability, provisions of the 21st Century Cures Act, permit the patient to control the sharing of their personal health information.

However, it poses practical system development problems. This issue must be resolved promptly; otherwise, it will lead to serious cybersecurity risks and patient data breaches.

Patient Consent The Office for Civil Rights (OCR) suggested changes to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to facilitate patient data access and sharing without the patient’s consent.

To address the privacy issues, it is crucial to enlighten healthcare providers and the general public about the significance of health information exchange.

Providers’ Participation Point-of-care devices give insights for patient interactions through care workflow and identify missed codes of previous diagnoses. These devices are critical for increasing provider participation to uplift the healthcare system.