How Risk Adjustment Software Helps Insurers Adapt To Modern Times

The Affordable Care Act, enacted in January 2014, has changed the face of healthcare in the United States. The bill is best characterized with the three Rs: Reinsurance, Risk corridors, and most importantly, Risk adjustment. Here’s how the risk adjustment program embedded in the Affordable Care Act (ACA) has changed how health insurers conduct business in America.

The Problem That Brought Us Here

The United States is a nation with a capitalist mentality. Historically, we have embedded our values in private enterprise. Government intervention, even for healthcare, is limited to senior citizens. There are many advantages to encouraging competition in the marketplace. But it also entails that the enterprise prioritizes self interest. This can create problems when it comes to health insurance.

For decades, insurers were notorious for denying applicants who had previously suffered illnesses. That included anyone who’d received treatment for conditions that could potentially become expensive for the insurance company in the future. But as a result, people who needed health insurance the most were often denied coverage, simply because they’d had a preexisting condition.

How Risk Adjustment Aims To Fix The Problem

Risk adjustment prohibits insurers from denying applicants the right to insurance due to preexisting conditions. Furthermore, insurers must relocate money that they earn from lower risk clients in order to help fund those with higher risk. This theoretically should eliminate the incentive of denial due to preexisting conditions. Instead, it’s more beneficial for companies to compete based on the quality of their care, and remain open to all applicants. Not just the ones who pose the least financial burden on the companies.

Hierarchical Condition Category (HCC) Risk Adjustment In 2016

The Centers for Medicare and Medicaid Services (CMS) first introduced HCC Risk Adjustment to us back in 1997. But never before has it been so relevant. It is a form of medical coding for billing that helps identify individuals who have chronic or more severe illnesses and conditions. They then assign a score based on the findings, which they determines the cost of care. This is all based on the International Classification of Diseases – 10 (ICD-10) system of codes. A risk adjustment factor score once was the dread of those who were too sick to receive care. Now it’s an opportunity to determine an appropriate plan of action for each patient moving forward.

How HCC Risk Adjustment Software Helps Us Adapt

Hiteks Solutions is a clinical documentation improvement (CDI) software company. We offer mobile device packages to healthcare facilities that allow them to determine an HCC Risk Adjustment score in real time. Our Real-Time CDI technology is appearing all across the nation, allowing insurers and healthcare providers to stay better in touch with patients, coders, documentation specialists.

We are headquartered in New York City but have clients all throughout the nation. Wherever there’s a need for improved documentation practices, we want to be there. For more information on our products, give us a call today at 212-920-0929, or feel free to reach out to us on our contact page.

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