Risk Adjustment

Risk adjustment is a method used in the health insurance industry to account for differences in the health status of enrollees in a health plan. The goal of risk adjustment is to ensure that health plans are not penalized for enrolling a population that is sicker or has more health risks than other plans.

This is important because if health plans were not adjusted for risk, they would have an incentive to avoid enrolling people who are more likely to need expensive medical care.

Risk adjustment is typically done by using a statistical model to estimate the expected costs of caring for a specific population of enrollees, based on their demographic and health status information.

This estimated cost is then used to adjust the payments made to the health plan. The plan that enrolls a population that is sicker, would receive more payment and vice versa.

Risk adjustment is typically used in government programs such as Medicare Advantage and Medicaid managed care, as well as in the individual and small group markets created by the Affordable Care Act.

Vim’s solutions improve risk adjustment performance. With Vim Diagnosis Gaps, payer-sourced suspected diagnoses are embedded directly into provider EHRs, surfacing patient-specific condition gaps and assisting providers in quickly and easily taking appropriate actions for accurate and efficient risk adjustment processes.

Vim Diagnosis Gaps helps providers achieve gap action rates of more than 85% on risk adjustment data.