Analytics Intern (Return) · Risk Adjustment Service Offering

What Risk Adjustment actually is.

Medicare Advantage plans get paid a fixed monthly amount per member, adjusted for how sick that member is expected to be. Risk adjustment is the CMS methodology that turns a member's documented health conditions into that adjustment. The idea is that a plan covering a sicker population should be compensated accordingly, and a member's expected health status should generally track year to year based on what's actually documented.

Where this sits

Risk Adjustment isn't separate from Revenue Cycle Management. It's the part of the cycle spanning Charge Capture through Insurance Follow-Up (highlighted above). Same cycle, different lens.

See the full revenue cycle

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Step 01 / 5

Diagnosis & Documentation

A condition is identified and recorded

During a patient encounter, a provider identifies and documents a diagnosis. For a health plan to get credit for managing that condition, it has to be captured clearly in the medical record. A real but undocumented diagnosis doesn't count for risk adjustment purposes.