# What is data mining in risk adjustment?

The process of analyzing large chunks of data to discover meaningful patterns and trends through complicated mathematical calculations that offer predictable outcomes.

Table of Contents

## What is data mining in risk adjustment?

The process of analyzing large chunks of data to discover meaningful patterns and trends through complicated mathematical calculations that offer predictable outcomes.

### Which of the following is a requirement for data to be submitted for risk adjustment purposes?

The five (5) minimum data elements that must be collected and submitted are: HIC (Health Insurance Claim) number, Provider Type From Date of Services, Through Date of Services, and Diagnosis Code.

#### How is risk adjustment calculated?

It is calculated by taking the return of the investment, subtracting the risk-free rate, and dividing this result by the investment’s standard deviation.

What is data mining in coding?

Data mining is the process of understanding data through cleaning raw data, finding patterns, creating models, and testing those models. It includes statistics, machine learning, and database systems.

Why is risk adjustment important?

Risk adjustment is an important opportunity to ensure the sustainability of the exchanges and coverage for patients with chronic conditions. If risk adjustment is not implemented correctly, many people could lose access to their coverage.

## What is an HCC score?

The CMS-HCC risk score for a beneficiary is the sum of the score or weight attributed to each of the demographic factors and HCCs within the model. The CMS-HCC model is normalized to 1.0. Beneficiaries would be considered relatively healthy, and therefore less costly, with a risk score less than 1.0.

### What is RAF CMS score?

A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient’s health status. RAF scores are used to predict the cost for a healthcare organization to care for a patient.

#### What are the risk adjustment models?

Risk adjustment models were created in the 90’s by academia and funded by CMS as a method to adjust capitated payments to Medicare and Medicaid HMOs. The models are designed to predict future expenditures of enrollees based on diagnosis codes reported on claims and encounters.

What is the difference between HCC and RAF?

HCC codes are additive, and some have multipliers. Population complexity/severity affects payment in many Medicare contracts. RAF is used for benchmarking for quality and safety. RAF enables identification and stratification for patient management.

What is the difference between CMS and HHS?

â€śCode all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment….How to use this information in practice.

CMS-HCC HHS-HCC
Developed for >65 year olds and disabled patients of all ages Developed for all age patients