Quality and Risk Workshop
It is well known that patients with multiple serious medical conditions have higher costs of care and require more resources. In a typical fee-for-service model there are limited mechanisms to recognize and address these discrepancies. Risk Adjustment is a model that adjusts reimbursement based on the presence or absence of serious medical conditions such as diabetes or heart failure. Over time, more accurate coding results in more accurate reimbursement. As we continue to evolve the health care system to a more closely aligned fee-for-value model, risk adjustment plays a key role and has the potential to truly align resources and care.
This activity will review the basics of the risk adjustment system in Medicare and how accurate and appropriate diagnosis, documentation, coding, and care lead to improved patient benefits, such as transportation, and lower copays—as well as improved reimbursement for health plans and providers. The activity will move from an overview to a condition-focused review.
This activity is jointly provided by OptumHealth Education and OptumCare.
No commercial support was received for this activity.
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These materials are intended only for those that attend the live activity on Monday, April 4, 2022. This activity is designed to meet the educational needs of physicians—including family physicians—and other health care professionals who have an interest in health care economics and risk adjustment.
At the end of this educational activity, participants should be able to
- Identify how risk adjustment provides an opportunity to align care across the health care delivery spectrum.
- Understand how accurate and appropriate risk adjustment leads to sufficient resources to increase patient benefits.
- Explain why medical practices should improve their documentation in response to the transition from fee for service to fee for value.
- Describe how to follow disease improvement or progression using ICD-10 codes reflecting the patient’s condition.
- Discuss how ICD-10 codes may be used in the pay-for-performance program.
- Discuss the level of detail required by the new system and how to improve accuracy and specificity in documentation.
Nikki Macalalad, MSN, APRN, FNP-C
Associate Director of Clinical Coding Education, CDQI
Southwest Medical Associates--part of OptumCare
Las Vegas, Nevada
Frederic M. Celestin, MD
Medical Director, Education Solutions
Clinical Performance at OptumCare
Tania Miedico, MD
Sarah Chart, RN
Rebecca Gleason, RN, CCM
V. Silverstein, MD
Eagle Creek Medical Communications
Durham, North Carolina
Disclosures of Relevant Financial Relationships
In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, OptumHealth Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.
The activity faculty and planners have no financial relationships to disclose.
In support of improving patient care, this activity has been planned and implemented by OptumHealth Education and OptumCare. OptumHealth Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.
Credit Designation Statements
OptumHealth Education designates this live activity for a maximum of 12.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
American Academy of Family Physicians
The AAFP has reviewed Quality and Risk Workshop, and deemed it acceptable for AAFP credit. Term of approval is from 10/02/2021 to 10/02/2022. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.
AAPC will honor 1-for-1 CEUs for any live event offering CME credit or AMA PRA Category 1 Credit™. A certificate of attendance or completion is necessary to show participation. The certificate will give the total CMEs possible for the offering. Physicians are advised to claim only the actual hours that they were present during the education. We ask that AAPC-certified members abide by this request also. One hour of instruction is worth 1 CEU.
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.
A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization to which you wish you apply credit.
- 12.00 AAFP - Family Physicians
- 12.00 AMA - Physicians
- 12.00 Attendance - General Attendance
You must be logged into your account to participate in this activity. Get started by entering the Access Code and clicking "UNLOCK". Then click “Continue”, complete the “Pre-Activity Assessment” and follow the prompts at the bottom of the screen. At the end of the activity, you will be able to view, save or print your certificate of participation. A complete listing of all of your activities can be found under “My Account,” “My Activities.”