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.