Risk Adjustment In Depth

Learn more about the benefits of coding specificity and you can optimize results for your practice.

How coding specificity will impact you:

  • Informed care practice. Supported by coding, claims-based analytics can help provide solutions and strategies for health care interventions and identify patients for disease and care management programs. More importantly, it helps to identify practice patterns and reduce variations, when clinically appropriate.
  • Accurate projection of medical expenditures for risk-sharing. Providing better insight on the true risk associated with patients, coding specificity impacts provider ability to project medical expenditures, based on health care utilization, for a given population. Coding specificity is critical for providers to successfully prepare for or further engage in risk-sharing arrangements.
  • Less paperwork, lower administrative burden. Accurate coding will minimize practice disruptions from both medical record requests and claim resubmissions, making resources available for other important practice initiatives.

How to get the best results:

  • Adopt technologies like electronic health records or voice translation software to improve accuracy and efficiency.
  • Fully document all applicable conditions for each patient you treat by including the appropriate ICD-10 codes on every claim submission.
  • Engage clinicians to accurately capture primary conditions and present co-morbidities, particularly in more complex cases.
  • Involve coders and office staff to ensure the use of coding best practices.
  • Standardize coding processes to minimize disruptions to the billing workflow.

Our vendors

Horizon BCBSNJ and the Blue Cross and Blue Shield Association have entered into Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreements with the organizations listed below to conduct risk adjustment efforts on our behalf.

The following organization: Has been selected to gather risk adjustment information for:
Episource Medical chart retrieval and coding for patients enrolled in Horizon BCBSNJ commercial and Medicare Advantage plans related to risk adjustment
Inovalon Medical chart retrieval and coding for patients enrolled in Medicare Advantage and commercial health insurance plans offered by other Blue Cross and/or Blue Shield plans related to risk adjustment
Matrix Medical Network Providing in-home assessments for patients enrolled in Horizon BCBSNJ commercial, Medicare Advantage (State Health Benefits Program retirees) and Horizon NJ TotalCare (HMO SNP) plans related to risk adjustment