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Risk Adjustment Programs

Risk Adjustment Processing Systems (RAPS) is a Medicare program whereby program payments are adjusted based on a higher assignment of members with chronic conditions. 

Because this is a government-administered plan, collection of accurate and complete diagnoses from providers each year is critical to the continuity of the plan. (Government systems do not carry diagnosis information over from the prior year).

To facilitate this documentation, WellCare engages providers in various methods to validate member diagnoses. These methods include:

  • Giving specific diagnosis history to providers to assist in updating current year documentation
  • Utilizing in-home assessments for members who have difficulty in accessing care or are homebound or for other factors limiting the plan’s ability to update diagnosis history
  • Retrieving medical records from providers to ensure diagnoses were completely and accurately submitted on the claims
  • Partnering with providers through incentive programs to ensure Quality and Health History goals (See below for details on current programs)

2016 Partnership for Quality Program

Two ways for PCPs to earn incentives:

1. Ensuring Eligible Members meet all applicable compliance criteria for the HEDIS® and Medication Adherence Program Measures, and/or

2. Completing a Continuity of Care “Appointment Agenda” to ensure Eligible Members receive appropriate care based on their health conditions.

Bonus payments will be quarterly, beginning on or around June 2016, with successive payments on or around August 2016, November 2016, and April 2017. In addition, qualified providers with a demonstrated history of strong quality measure performance – and/or who return Appointment Agendas timely – are eligible for higher Bonuses.

Bonus payments will be contingent upon compliance with the terms and conditions of the P4Q Program Description. If you have questions about our P4Q Program, please contact your Provider Relations Representative, or call Provider Services at 1-855-538-0454 (TTY 1-877-247-6272). You can reach us Monday–Friday, 8 a.m. to 6:30 p.m.

Risk Adjustment Program Resources

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Last Updated On: 5/17/2018