What is Risk Adjustment?

Risk Adjustment is a statistical process that accounts for the underlying health status of patient populations when measuring healthcare outcomes, determining provider performance, or calculating payment rates. It enables fair comparisons by acknowledging that some patients inherently require more healthcare services due to more complex or severe medical conditions.

Why is Risk Adjustment important?

• Payment fairness: Ensures providers serving sicker populations receive appropriate compensation.
• Accurate comparisons: Enables valid quality measurement across different patient populations.
• Access protection: Prevents disincentives for treating high-risk or complex patients.

Common applications of Risk Adjustment

• Medicare Advantage and ACA marketplace plan payment calculations.
• Provider performance measurement for value-based payment programs.
• Research studies comparing outcomes across different populations.

How Solace can help

A Solace advocate can help you understand how risk adjustment affects your insurance premiums or coverage options, ensure your medical conditions are properly documented for accurate risk assessment, and address concerns about access to care if you have complex health needs. They can also help explain how your providers might be evaluated under risk-adjusted quality measures.

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