Improve Medicaid risk adjustment accuracy

Whether Medicare or Medicaid, risk adjustment programs reimburse health plans for the risk of beneficiaries they enroll. Risk adjustment programs help health plans balance costs by accurately identifying health status and associated costs for each member.

This is where the similarities end.

Medicare Advantage

• Administered by the Centers for Medicare and Medicaid Services (CMS)
• Health plan reimbursement paid at member level based on member risk scores
• Total reimbursement amount paid with approximately a year lag time

Medicaid

• Administered by individual states
• Health plan reimbursement paid at member level based on member risk scores
• MCO reimbursement paid at plan level based on the plan’s risk scores at the category of aid level
• Timing for reimbursement varies by state. For example, some states take up to 24 months from risk score identification to reimburse MCOs.

Documenting the health status of Medicaid populations accurately is very important to your risk adjustment program. Narrow margins associated with managed Medicaid plans can make the difference between profit and loss. Those margins can be affected directly by the accuracy of your risk adjustment practices. Because states base risk scores off claims, reimbursement you receive will be only as good as the claims you submit.

The following actions may help maximize the potential of your risk adjustment efforts to represent your population’s health status accurately. This may help improve health outcomes and close gaps in care:

Empower providers 

Give timely, actionable data at the point of care. This may help ensure that a member is fully assessed for undiagnosed health conditions.

It is important for providers to document and code diagnoses accurately.

Engage patients 

Promote preventive and wellness visits. When members have regular visits, providers can diagnose and document health conditions.

However, this is easier said than done. Patients may not understand their health benefits, have the means to get to their visits, are not physically able to leave their homes or are afraid to go to the doctor.  

Providing education about their health conditions and health benefits may contribute to better engagement and health outcomes.  

Review charts

Be sure providers identify all health conditions and that staff codes and submits all conditions correctly.

Complete and accurate information helps states compare and assess all risk scores for health plans providing health coverage in Medicaid markets. 

They are. Closing gaps in care is the main goal of an effective risk adjustment program and that may help create a positive impact all around.

Patient healthcare outcomes may improve as may risk scores. When your risk scores improve, your bottom line may improve.

Work with a partner that:

• Has experience working with state Medicaid requirements
• Health plan reimbursement paid at member level based on member risk scores
• MCO reimbursement paid at plan level based on the plan’s risk scores at the category of aid level