Risk Adjustment Process

Risk adjustment, a component of Medicare Advantage and the Affordable Care Act (ACA), helps align payments to health plans with the risk characteristics of people enrolled in each plan.

Accurate risk adjustment relies on comprehensive, face-to-face health assessments of patients. These assessments result in appropriate medical record documentation and diagnosis coding. The diagnosis codes are then submitted to the health plan on a claim and used to determine the level of risk associated with the patient.

Florida Blue has risk adjustment programs in place that align with our commitment to ensuring that quality of care is maintained through the physician-patient relationship. These programs help identify care and coding opportunities that can help prevent and/or detect conditions and encourage members to schedule health screenings, tests and vaccines.

RPM Revenue Program Management

For More Information

If you have questions or want to learn more about risk adjustment refer to the following:

Read our monthly newsletters.

• Read about important changes regarding Comprehensive Quality & Risk Program On Hold Effective Jan. 1, 2018
• Read this document on the risk adjustment process.
• Complete training or attend a webinar through the Availity®¹ learning center.
• Read FAQs on the Comprehensive Quality & Risk Program.
• Send an email to RiskAdjustmentTraining@bcbsfl.com.

¹ Availity, LLC is a multi-payer joint venture company. For more information or to register, visit availity.com.