This course provides attendees with the training required to answer provider questions about the Medicare Advantage CMS-HCC Risk Adjustment policies as defined by CMS and implemented by various third-party Medicare Advantage Organizations (MADs) in accordance to the Balanced Budget Act of 1997.

The CMS-HCC Risk adjustment methodology importance is explained because itensure more accurate payments to Medicare Advantage organizations based upon the health status of their enrolled beneficiaries . As a result, risk adjustment strengthens the Medicare Advantage program, thus placing member into the appropriate risk category for expected resource allocation.

A fundamental knowledge of the history of this particular capitated payment methodology based on patient risk, including the current political climate and government mandates as required by the Affordable Care Act will be delivered to help explain the purpose and rationale of the Risk Adjustment program. In addition, the importance of proper chart documentation and ICD-9-CM diagnosis coding to the highest level of specificity will be emphasized for accurate Risk Adjustment payments.

This information will develop an understanding of payment programs based on government reimbursements for high risk members to help keep membership premiums affordable to all participants, improve the quality and quantity of risk adjustment data submitted, and, thereby, to more accurate funding by CMS to support medical necessityand resource allocation, and to improve other government sponsored quality and rating program metrics.