The implementation of health reform requires Medicare Advantage plans to define how they are going to position for rate reductions which started in 2011.  The maintenance of revenue will not result from membership growth for members with little disease burden.  Careful  management of members with multiple chronic disease and documentation of their care, will lead to effective outcomes and adequate revenue from risk adjusted payments.  At the strategic level, a Medicare Advantage plan needs to look at who they market their services to, and attract physicians who are effective in the treatment and management of patients with high disease burden, as well as design care management programs which address  the needs  of diabetics, patients with COPD,  CHF, heart disease and the chronically ill. 


The Menu Bar on the right of this page,moves the user through the definition of the risk adjustment payment model and Hierarchical Condition Categories (HCC), training materials, electronic medical records, and useful links to firms and sites that address the needs of  the risk adjustment business transformation. Review your own risk adjustment program against the elements in the Menu Bar. 


Medicare compliance requires accurate documentation in medical charts. The same rules as in fee for service apply when quality improvement interventions are implemented. Quality improvement initiatives need to be reviewed and documented for compliance purposes. Review the compliance model under the Menu Bar, since the consequences of an ill-conceived risk adjustment program are substantial when placed under Inspector General review.  The  SCAN  Health Plan decision by the Department of Justice is also reviewed.


The annual documentation of disease burden is a systematic approach to the treatment and documentation of chronic disease which is rewarded in the payment model. The  training materials are designed to support the education of physicians in this process. There are 60 slides which take  90 minutes to present. Initial assessment of new members by physicians or nurse practitioners trained in the HCC model can establish a more accurate baseline HCC score. Firms which offers services are listed in the Risk Adjustment Service Providers tab.


Care management of chronic disease is encouraged in the risk adjusted payment model. Case management of the patients with  multiple chronic disease can start with risk stratification of high risk score members.

The medical home demonstration also employs risk adjusted  payment  to encourage innovation in the delivery system. The Accountable Care organization may also have risk adjusted capitation / incentive payment based on fee for service initial payment.


The information systems which support  care processes are an essential area for redesign. The process redesign can include areas such as patient scheduling. The chief complaint entered by the scheduler of the patient visit can be redesigned to address  a patient's chronic disease.   High risk patients can be triaged for same day appointments to avoid an emergency room visit. Nursing home patients can be scheduled for chronic care. Review of  discharge summaries is  another area for process change. The physician office can be redesigned to include nurse case managers with chronic  care case loads.

There are applications which provide cost accounting by HCC, diagnosis summaries and edits which prioritize patients for annual documentation of disease as well as highlight physicians who have adapted their practices to the risk adjustment model. These applications can tarck the documentation of disease burden in comparison to the previous years date of service to provide attention to the physicians which still need to know which patients require  documentation before the end of the calender year.         


Please  join the linked in Medicare Risk Adjustment group  and contribute your ideas to the business transformation which is under way in many organizations.We have over nine hundred professionals from around the county, in many disciplines. who can bring their experience to questions you many have in a new discussion topic. We all can learn from each other as the health care delivery system is renewed under a revised financial model for care. 

The CMS Medicare Managed care Manual chapter 7 is  in the folder below  as reference documentation for the Risk Adjustment model.  

Jim Swoben