Where Coding Takes Us

Risk Adjustment and Controversy

Risk adjustment is a payment tool that is coming under greater levels of scrutiny, particularly given some recent journalism that presented a very slanted view of the practice as it relates to the popular Medicare Advantage program that provides health coverage to roughly 30% of Medicare beneficiaries. While this series of articles is critical of the health insurance industry, it mixes a string of worthwhile and valid points with a large dose of bad information and invalid accusation (http://www.publicintegrity.org/).

Putting this into perspective requires more than tough soundbites. It requires some understanding of what the government and the industry are really trying to do and how they are going about it. But the result of misinformation is predictable when public trust of their insurance companies is extremely low and this distorted picture tends to confirm what they want to believe about this industry. What needs to be properly understood is why diagnostic information is crucial to healthcare reform, how it is being used for payment methods and how it is being used for the benefit of patients in terms of quality of care, healthcare outcomes and continuous improvement of the healthcare system. In addition, there are several areas of caution that must be watched and policed for potential abuse and misuse, which is completely supported by the industry as a whole. 

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