risk adjustment: impacts, benefits and key insights · by icd-10-cm codes submitted via claims....

Risk Adjustment: Impacts, Benefits and Key Insights

Horizon BCBSNJ supports three risk adjustmentprograms: – Commercial risk adjustment – Medicare Advantage risk adjustment – Medicaid risk adjustment

The risk adjustment programs rely on accuratelycoded claims and accurately documented medicalrecords. Understanding and reporting a patient’strue risk helps stabilize premiums and protectpatients against the negative effects of adverse risk selection.1

Accurate and complete coding allows HorizonBCBSNJ to correctly identify patients who couldbenefit from our Chronic Care and Complex CaseManagement programs. These programs, offeredfree of charge, focus on education and improvingthe health of our members.

Benefits of risk adjustmentRisk adjustment provides many benefits, including:– Better health management – Decreased administrative burdens– Clinical documentation education and feedback

Physicians and other health care professionals areasked to code for any condition that is monitored,evaluated, assessed or treated (M.E.A.T.) during thepatient’s visit. Documentation should also includeall medical conditions affecting the managementand/or treatment of the patient and accuratelyreflect the patient’s overall level of disease severity.1

The following activities, at least yearly, candecrease administrative burdens by reducingretrospective chart retrieval requests:– Thoroughly documenting all medical conditions (acute, chronic, status and history)– Accurately coding to the highest level of specificity – Reporting all coded conditions on the claim

The patient’s medical record can provide additionalinsight into his or her condition, which may not be found in the claims. Also, reviewing charts on ayearly basis helps Horizon BCBSNJ look for ways to improve clinical documentation and adhere withthe Centers for Medicare & Medicaid Services(CMS) and ICD guidelines.

Using unspecified codes does not allow for accuratedisease identification, which results in patients notbeing included in our Chronic Care and ComplexCase Management programs. Additionally, the useof unspecified codes may require the submission ofmedical records to appropriately identify a patient’shealth status and accurately recognize his or herrisk.2

To achieve consistency and ensure the highestlevel of quality care is provided, patients with chronic conditions must be monitored,evaluated, assessed and/or treated at least once per year.

Horizon Blue Cross Blue Shield of New Jersey helps physicians and other health care professionalsbetter understand risk adjustment. Risk adjustment impacts you and your patients. It is important todocument your medical records and code to the highest level of specificity aligned with theInternational Classification of Diseases, Tenth Revision (ICD-10-CM).

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With a focus on providing quality of care for our members, your patients, healthier outcomes can be achieved.

For additional information, visit: HorizonBlue.com/riskadjustment.

Risk Adjustment ProgramsCommercial Risk Adjustment (CRA) – isadministered by Horizon BCBSNJ as a result of theAffordable Care Act (ACA) and is overseen by CMS.Most Americans are required to maintain healthcare coverage and risk adjustment seeks to facilitateaffordable coverage regardless of the patient’shealth status. These are members insured throughour small group and individuals plans that purchaseinsurance on or off the Health InsuranceMarketplace. CRA products are primarily HorizonAdvantage EPO and OMNIASM Health Plans, butalso include HMO, Direct Access and Point-of-Service with a metallic identifier after thename of the product (e.g., Bronze, Silver, Gold).3

The risk is captured through a combination of ICD-10-CM codes submitted via claims and medicalrecord reviews. The chronic conditions must besubmitted on an annual basis.1, 2

Medicare Risk Adjustment – is administered byHorizon BCBSNJ and is overseen by CMS. The primary plans are Horizon Medicare Blue (PPO),Horizon Medicare Blue Value (HMO), HorizonMedicare Blue Patient-Centered w/Rx (HMO) andFully Integrated Dual Eligible Special Need Plans(FIDE-SNP). Like CRA, Medicare risk is capturedthrough a combination of ICD-10-CM codessubmitted via claims and medical record reviews.The chronic conditions must be submitted on anannual basis.4

Medicaid Risk Adjustment – is administered byHorizon NJ Health and is based on the guidelinesfor the state of New Jersey. Risk is captured solelyby ICD-10-CM codes submitted via claims. Claimsshould be filed for every encounter, even if theservice is capitated.

By keeping the acronym M.E.A.T. in mind, coding ofall symptomatic and underlying conditions on anannual basis will support the success of the riskadjustment programs.

If you have any questions about the risk adjustmentprograms, a Provider Educator is available to assistyou.

Name Contact Counties

Monique Hodge

Monique_Hodge@HorizonBlue.com1-973-466-6706

Atlantic, BergenCamden, HudsonMercer, Monmouth, Ocean and Somerset Counties

Kevin Jennings

Kevin_Jennings@HorizonBlue.com 1-973-466-4623

Burlington, CapeMay, Cumberland, Essex, Gloucester, Hunterdon, Middlesex, Morris, Passaic, Salem, Sussex, Union and Warren Counties

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Products and services are provided by Horizon Blue Cross Blue Shield of New Jersey, Horizon Insurance Company and/or Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator ofprograms and provider relations for all its companies. All are independent licensees of the Blue Cross and Blue Shield Association. OMNIASM is a service mark of Horizon Blue Cross Blue Shield of New Jersey. The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2019 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, New Jersey 07105. EC002913B (0219)

1. Florida Blue Quality Revenue Program Management. Risk Adjustment, Medicare and Commercial. 2. Willis, M. (2014, March 3). ICD-10 Monitor. Unspecified or Specified? Retrieved from http://www.icd10monitor.com/enews/item/1133-unspecified-or-specified 3. Horizon Blue Cross Blue Shield of New Jersey 2016 Managed Care Benefits-at-a-Glance. April 2016. 4. Clinic Service. What is a Medicare Risk Adjustment Factor (RAF)? Retrieved from http://clinicservice.com/what-%E2%80%9Cmedicare-risk-adjustment-factor-raf%E2%80%9D/