What is CMS risk adjustment?

Risk adjustment promotes fair and accurate comparison of healthcare outcomes across healthcare organizations and providers. Risk adjustment refers to the inclusion of risk factors associated with a measure score①in a statistical model of provider performance captured at the person, facility, community, or other levels.

What is the CMS HCC risk adjustment system?

The CMS-HCC model is a prospective risk-adjustment tool implemented by CMS in 2004 to estimate future expenditures for Medicare beneficiaries.1 It was initially employed by CMS to adjust capitation payments to MA plans but is now used to calculate expenditure benchmarks for MSSP ACOs as well.

What is CMS risk score?

The Risk Score Files are created from the final CMS risk adjustment model outputs for a payment year. These risk scores are used to adjust CMS payments to Medicare Advantage (Part C) plans to account for differences in relative costs among plan enrollees.

What is CMS HCC stand for?

HCCs, or Hierarchical Condition Categories, are sets of medical codes that are linked to specific clinical diagnoses. Since 2004, HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions.

What is the risk adjustment processing system ( raps )?

The Risk Adjustment Processing System (RAPS) – Introduces the Risk Adjustment Processing System (RAPS), the format and flow for submitting risk adjustment data, and the timeline for RAPS submissions. 5. Reports –

What does CMS use to calculate risk scores?

Historically, CMS has used diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS) by MA organizations for the purpose of calculating risk scores for payment. In recent years, CMS began collecting encounter data from MA organizations, which also includes diagnostic information.

How does a risk adjustment program work for Medicare?

Risk adjustment programs get demographic information from the enrollment application. Whether applying for Medicare, Medicaid, or commercial insurance, there is an application process. The programs use a person’s Social Security number, permanent address, and medical and financial questionnaires to establish enrollment.

When to use HHS certified alternate risk adjustment methodology?

• HHS is developing a risk adjustment model for the nonelderly population to be used when HHS is operating risk adjustment on behalf of a State. States operating a risk adjustment program may choose to use this model or an HHS certified alternate risk adjustment methodology 10 Risk Scores • Individual risk scores