TotalCare (HMO D-SNP) Risk Adjustment Program

The TotalCare (HMO D-SNP) Risk Adjustment Program enables the Alliance to support the cost of providing health care services to its members. The Centers for Medicare & Medicaid Services (CMS) payment model uses demographic factors and qualifying diagnoses to calculate a member’s risk score.  

Each member in the plan is assigned an individual risk score that reflects their expected health care needs and costs. 

CMS applies a Hierarchical Condition Category (HCC) Model, in which qualifying diagnoses are mapped to specific condition categories. Additionally, CMS has strict criteria looking at diagnoses captured from a face-to-face encounter by an acceptable provider type and setting. 

Benefits of risk adjustment

• Supports patient care by clearly communicating the patient’s true health conditions and complexity across the care team, health plan and CMS.
• Supports quality and regulatory activities such as HEDIS and Risk Adjustment Data Validation (RADV) audits/reviews.
• Helps reduce administrative burden by making sure everything is submitted correctly on the first round.
• Supports accurate reimbursement by ensuring coded conditions reflect the level of care and resources needed by the patient.

What makes a risk adjustment program successful?

Risk adjustment is a collaborative effort of coordinated care between providers and the health plan, involving:

• A robust communication loop: Effective and frequent communication between the Alliance and providers helps ensure the best health outcomes for members.
• Clinical medical records: With the help of providers, the Alliance can receive medical records to review and ensure that data is received as quickly and efficiently as possible. Health care providers need to annually assess and document each patient's active health conditions within the clinical medical record.
• Clear, complete documentation and data: This includes patient demographics, encounter data, health status and diagnoses.
• Technology: The Alliance uses Cozeva as its point of care tool to assist providers with receiving real-time data that can be used during patients’ visits. Read more about the platform below.

Cozeva

Cozeva is an online platform that can be accessed through the Alliance Provider Portal with SSO account creation. The platform captures all claims data, such as hospital inpatient stays, lab results and specialist encounters. It displays the historical chronic conditions that members had.

The goal is to ensure that member encounters that occur outside of the provider’s Electronic Health Record are surfaced to the primary care provider during a patient encounter.

Note: Clinical documentation occurs in the provider’s EMR, not within Cozeva. Cozeva is a tool that identifies members’ preexisting conditions and suspected conditions. The care team can use Cozeva to either confirm or disconfirm conditions in real time.

Accessing Cozeva

Physicians and office staff receive access to Cozeva based on specified roles and responsibilities. During Cozeva provider training, Alliance staff goes over all available roles and determines most appropriate levels of access.
If you have questions about getting access to Cozeva, reach out to your assigned Provider Relations Representative. You can contact Provider Services at 831-430-5504.

How is risk adjustment different from Fee-for-Service coding?

Fee-for-Service reimbursement generally focuses on the services provided, while risk adjustment uses qualifying diagnosis information to help reflect a patient’s overall health status and expected health care needs. Each condition must be supported by the medical record and reported using ICD-10-CM coding guidelines and applicable CMS requirements.

The goal is not to document more diagnoses, but to accurately capture the patient’s health status based on the care provided and documented during the encounter.