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Certain quality programs run by the Centers for Medicare and Medicaid Services (CMS) and other payers use Risk Adjustment Factors in order to determine fair payment for providing health services and benefits for a population of patients. These programs use a set of models known as Hierarchical Condition Categories (HCC), which are tools that look at a patient's demographic and diagnostic information in order to assign the patient a specific degree of "risk." Risk correlates to two major factors that affect patients and payers:
- the general quality of a patient's health, determined by age and chronic conditions, and their likelihood of needing care in the immediate future.
- the health care costs associated their quality of health
In other words, a patient with a high risk score is more likely to require more care, and is more likely to incur higher health care costs.
Factors that used when calculating the patient health risk includes:
- Patient demographics (age and gender) for patients over 65 and patients of any age who are institutionalized
- Chronic condition diagnoses, based on ICD-10 codes selected in the patient’s problem list
- Certain co-morbidities
- A normalization factor to adjust beneficiaries’ risk scores so that the average risk score among Medicare Beneficiaries is equal to 1.0.
- A coding intensity factor, which adjusts for the difference between Medicare Advantage and fee-for-service coding.
- Adjustments for if the patient is institutionalized or in a community
A lower score indicates a less severe status; where 1.0 is the average score for Medicare beneficiaries.
Elation’s Risk Assessment score provides a snapshot into the severity of a patient’s health risk. The algorithm used to determine the Risk Score is a close correlation with the 2024 Centers for Medicare and Medicaid Services’ (CMS) Risk Adjustment Model, which is a blend of Risk Model version 24 (67%) and Risk Model version 28 (33%) and the HCC scoring system. Elation's Risk Assessment Score can be used as an estimate of the risk that CMS will calculate for your patient given all available data you document into your patient's chart (patient demographics and diagnoses).
Elation’s Risk Assessment feature enables you to:
- get visibility into patient risk levels and adjust care plans accordingly
- ensure that high-risk problems are regularly addressed during the encounter
- accurately document the care you deliver with a complete understanding of the relative risk weights of various ICD-10 codes
- improve coding specificity and associated reimbursements when evaluating patient risk
- remain successful when participating in value-based care programs like the Direct Contracting Entity or Medicare Advantage programs
Follow the instructions in the Risk Assessment Guide to begin using Elation's Risk Assessment feature in your day to day clinical workflows.
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