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 QRPM newsletters.

Archived QRPM Newsletters

• Read about coding details and tips in our Florida Blue Medicare and Commercial Risk Adjustment Best Practices and Coding Educational Guide 2020.
• Read about online documentation and coding training that earns you continuing education credits.
• Read about important changes regarding Comprehensive Quality & Risk Program On Hold Effective Jan. 1, 2018
• Read about our risk adjustment process, including documentation and coding, quality data and how accurate coding affects your practice.
• 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.