The PCP’s assessment of a specialist or other healthcare provider’s diagnosis carries the most weight in discerning the severity and clinical validation of a condition. While a specialist’s diagnosis counts toward a patient’s risk score, the specialist is likely to focus on a single body system and see a patient only once or twice a year. Additionally, PCPs have long-standing relationships with their patients, putting them in a unique position to better evaluate the complete clinical picture and document all chronic conditions that coexist. 

Risk adjustment ensures the appropriate funding is available so the cost of patient care is covered and providers have the resources they need to care for these patients. Ultimately, it benefits all stakeholders—insurers, providers and patients. 

MA plans cover valuable services not covered by Original Medicare. The list includes prescription drugs, vision, hearing and dental benefits. MA plans cover care management for patients with chronic conditions or multiple complex conditions. Many MA plans provide a fitness benefit and address social determinants of health with transportation to appointments, healthy food and even changes in the home to address issues such as unsafe stairs or poor air quality.   

Risk adjustment was implemented in MA to ensure equity and fairness in coverage. By adjusting payments to health plans based on the patient’s health status, MA discourages health plans from “cherry picking” healthy patients. RA also helps ensure that health plans and providers have the resources to care for all patients, regardless of health status.   

Health plans are required by regulations to use at least 85% of the premium—including funds attained from risk adjustment—for medical expenses. The additional reimbursement is used to ensure funds are available for the services the patient needs. This includes care management for those with chronic conditions or multiple complex conditions. Many plans offer services to help address social determinants of health such as transportation to appointments or nutritious food. Funds are also used for additional benefits such as hearing, vision, dental and fitness benefits.  

While we can’t speak for all payers, our payer clients understand the work providers are asked to do daily and provide Vatica’s services to support them. They want providers to focus on patient care and count on Vatica to help them code and document accurately. These payers compensate providers for risk adjustment efforts via incentives for a process that, with Vatica’s support, takes, on average, 2–4 minutes per patient.