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Risk Adjustment/Patient Acuity Program

Risk Adjustment, also known to many as Patient Acuity is an effort by all Insurance companies to evaluate the amount of care required for our disabled, elderly, chronically ill and low-income population. The ultimate goal being to gain a complete picture of the health status of each of our members and ensure they get the care necessary to manage any conditions they have.

What is Risk Adjustment?

A statistical technique used to compare the health risk of populations enrolled in health plans, such as Medicare Advantage.  Simply Stated, if the individuals in group A are older and have more health problems than individuals in group B, you can expect the cost of group A’s healthcare to be higher. Risk Adjustment calculates a relative risk score for each individual, which can be accumulated to compare groups.


Whether risk adjustment is used for Medicaid, Medicare, or Commercial health plans, the methodologies all use ICD-10 diagnosis codes to define the health conditions of each member during each year. Medicaid and Commercial utilize filled Pharmacy prescriptions as well.

Medical providers document the diagnosis codes on claims submitted to the health plan, and the completeness and specificity of the codes is a critical factor to determine the risk score. A member with multiple chronic conditions will have a higher risk score than a member with no conditions.

The disease categories mainly represent chronic conditions that are likely to persist and link to additional medical expense. However, many acute conditions related to low-income populations are included in the model. Recognizing that not all risk is described through chronic disease categories, the risk adjustment models incorporate additional demographic factors to estimate medical resources not contained in one of the conditions listed in the hierarchy.

Risk Adjustment Accuracy Programs

The goal of any plan is to have an accurate picture of the health status of our membership. The following programs currently exist to work with membership or providers in order to obtain this accuracy.

  • Chart Review – A vendor or a plan employee may reach out to the provider office in order to obtain medical charts for select members of our plan.  Not all diagnoses are always required per claim. However, that does not mean a condition was not evaluated.  These charts are subsequently reviewed to order to compare the chart to submitted claims.
  • In Home Assessments (IHA) – Select members of our plan are offered an IHA, to be performed by a nurse practitioner.  The assessment is a comprehensive exam of their current medical health status.  Approximately two weeks after completion the assessment results are sent to the member’s PCP office for awareness.
  • In Office Assessment (IOA) – Formerly known as the Healthcare Quality Patient Assessment Form (HQPAF)  – The IOA program promotes early detection and ongoing assessment of chronic conditions for our clients’ Medicare Advantage and Medicaid Managed Care Plan members. The goal of the IOA program is to help ensure that these patients receive a complete and comprehensive annual assessment.  Forms are mailed out throughout the calendar year and providers are incentivized to complete them within a timeline to receive those incentives.
  • HCC Recapture – The Continuity of Care Program (Formerly P4Q) has an HCC Recapture component to the program.  The HCC Recapture program promotes early detection and ongoing assessment of chronic conditions for our members. The goal of the HCC Recapture program is to help ensure that these patients receive a complete and comprehensive annual assessment.  Appointment Agenda forms are available electronically or can be provided via other means, upon request, throughout the calendar year and providers are incentivized and that amount can increase based on how many of the Appointment Agenda forms are submitted.
  • PCP Visit Initiatives – PHW will continuously be evaluating our membership to see who may benefit from a PCP visit and has yet to have one.  We will outreach to these members to assist them in scheduling an appointment with their PCP.


PA Health & Wellness is committed to maintaining an open line of communications to all providers for any questions they may have on any of the risk adjustment programs or to collaborate on other risk adjustment activities.

For that reason we have established – this email will distribute communications to the PHW Risk Adjustment team and the PHW Provider Relations Managers. The Risk Adjustment team will triage all communications and will respond as soon as possible.