Failure to capture current conditions each calendar year results in ____.

Failure to capture current conditions each calendar year results in ____.

• A. Underpayment to the health plan.
• B. Overpayment to the health plan.
• C. No impact on payment.
• D. Denial of all claims.

Answer: (A)

Capturing current conditions for the year determines the risk adjustment score that sets how much the health plan is paid. If those conditions aren’t documented and captured in the calendar year, the risk score is understated. Since payments are tied to that risk score, underreporting health risks leads to underpayment to the health plan. It isn’t about denying all claims or having no impact—the chart would simply reflect a lower payment than warranted. The fix is thorough annual documentation of all current diagnoses so the payment reflects the patient’s true health status.

Capturing current conditions for the year determines the risk adjustment score that sets how much the health plan is paid. If those conditions aren’t documented and captured in the calendar year, the risk score is understated. Since payments are tied to that risk score, underreporting health risks leads to underpayment to the health plan. It isn’t about denying all claims or having no impact—the chart would simply reflect a lower payment than warranted. The fix is thorough annual documentation of all current diagnoses so the payment reflects the patient’s true health status.