Risk Assessments

Additional Information


Why is health quality measured and reported?
It gives consumers and employers the basis to make informed decisions and pursue the best available care. It also gives feedback to health plans, medical groups, and doctors to improve quality issues.

How is it measured?
Surveys (on and off-site), audits, satisfaction surveys, clinical performance measurements, and more. We use these approaches in a range of accreditation, certification, recognition and performance measurement plans for different types of organizations, medical groups and even individual physicians.

How does OHP ensure compliance?
At OHP we gather quality information and make it available to consumers, employers, health plans and doctors through these strategies:

  • Ensures compliance with applicable regulations related to coding and documentation guidelines for Risk Adjustment (federal, state, and county laws).
  • Thorough review of patients’ medical records, inclusive of patient medical history and physical exams, physician orders, progress notes, consultations reports, diagnostic reports, operative and pathology reports, and discharge summaries in order to verify whether:
    • the diagnosis codes are supported by the documentation and comply with ICD –10– CM Guidelines for Coding and Reporting.
    • the diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted time frame.
    • any diagnosis code is unsubstantiated by the record and should be eliminated. A review is applicable for clinical indicators and query providers to capture the severity of illnesses of a patient.

How do we ensure reimbursement?
OHP MSO ensures consistent physician and facility reimbursement by automatically evaluating provider claims in accordance with accepted industry coding standards thanks to a comprehensive nationally recognized code auditing system to secure consistent physician and facility reimbursement. We constantly enhance and update our code-editing technology to better enforce existing payment guidelines.

Claims will be reviewed to:

  • Reinforce compliance with standard code edits and rules.
  • Ensure correct coding and billing practices are being followed.
  • Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology and anesthesia codes.
  • Ensure compliance with industry standards.

Correct coding guidelines are established by:

  • The Centers for Medicare and Medicaid Services (CMS).
  • The American Medical Association (AMA) CPT Coding Guidelines.
  • National and Local Coverage Determinations (NCD/LCDs).
  • National specialty and academy guidelines.

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