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Hierarchical condition category and Centers for Medicare & Medicaid Services model - Research Paper Example

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This research paper will mainly focus on the Hierarchical condition category and Centers for Medicare & Medicaid Services model. It will go ahead and give its principles, organization of the model and the segments used in this model. In the paper, there is a diagram to show the versions of this model. …
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Hierarchical condition category and Centers for Medicare & Medicaid Services model
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Hierarchical condition category and Centers for Medicare & Medicaid Services model

The paper tells that one of the methods used in amending health plans capitation payments is risk amendment. This can be either lower or higher to explain the differences in the health costs expected for individuals. Insurers in establishing their revenue necessities are using various factors and medical expenditure trends. The models of adjusting risks used, determine the monthly capitation fee for every enrollee. The expectations of these models are supposed to be accurate. The model for Hierarchical condition category uses mainly demographic information such as sex and age. On the other hand, it uses medical condition profiles in order to calculate the following year’s expenditures in Medicare. It is standardized on the fee for service population because it gives full and complete data on Medicare claims unlike the Medicare advantage population. While developing this model, establishing diagnosis codes are to be taken account of; their grouping and how these groupings work together for the purposes of risk adjustments was a vital step. The first principle states that groups of diagnostics are supposed to be meaningful in a clinical manner. Every diagnostic group is part of the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The codes issued are supposed to relate with a medical condition or a specified disease that identifies the category. The conditions issued are supposed to be adequately specified in a clinical way in order to diminish the discretionary coding or gaming opportunities. The face authority of the system of classification to the clinicians is improved by the clinical meaningfulness. On the other hand, the clinical meaningfulness improves superiority, monitoring disease organization utility and interpretability. The second principle is the prediction of the medical expenditures by the diagnostic groups. The diagnoses in the similar Hierarchical condition category are supposed to be homogenous with effects respect on the future and current year’s costs. The third principle is the diagnostic groups, those that are assumed to have an effect on payments are supposed to be adequate in their illustration size for correct expenditure estimates. These diagnostics used in payment establishment are supposed to have sufficient illustration sizes in the data sets accessible. The fourth principle is the use of hierarchies in creating a clinical profile of a person (American Academy of Actuaries, 2010). This is to distinguish the level of illness of a given person while the disease effects are accumulating. These disease effects are expected to increase the medical care costs because every medical issue adds up to a disease trouble of an individual. Disease conditions that are related in one way or the other are supposed to be hierarchically treated. The fifth principle is the encouragement of diagnostic categorization in encouraging detailed coding. Diagnostic codes that are assumed indistinct, are supposed to be classified with less severe categories of diagnostics in order to give incentives for a diagnostic coding that is specific. The sixth principle is the classification of diagnostics that are not supposed to be issued with any coding creation rewards. It is not supposed to determine an immense burden of ... Read More
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