Skip to Main Content

Risk Adjustment

What is Risk Adjustment?

Risk Adjustment is a statistical technique that calculates a relative risk score which can be accumulated to compare health risk of a population of Individuals enrolled in Medicare Advantage Plan, Commercial Health Plan, and/or Medicaid.

Risk Adjustment process is regulated by CMS (Centers for Medicare and Medicaid Services).  The CMS Risk Adjustment model measures the disease burden that includes the HCC categories (Hierarchical Condition of Categories, which are correlated or linked to corresponding ICD 10 diagnosis codes.

HCC coding is prospective in nature. Diagnosis codes reported on your claims determine a patient’s disease burden and risk score. Reporting the appropriate diagnosis code and complete clinical documentation by the provider increases the member’s risk score. The disease categories mainly represent chronic conditions that are likely to persist leading to additional medical expenses if not addressed.

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 the member’s health status and the acuity of their conditions.

PA Health and Wellness (PHW) Risk Adjustment Department’s priority focus is to collaborate with all health care providers in support of Hierarchical Condition Category (HCC) risk adjustment efforts. There are various types of Risk Adjustment programs that are used by PHW to assist our providers: HCC Accuracy Program (Continuity of Care/COC), In Office Assessment (IOA), RADV (Risk Adjustment Data Validation), Chart Review, and In Home Assessment (IHA).

PA Health and Wellness Risk Adjustment Resources/Tools