Certified Risk Adjustment Coder (CRC)

For commercial plans, what influences funding allocation?

1. The previous year's known diagnoses

2. Only the current year's known diagnoses

3. Projected diagnosis codes for the next year

4. Audited diagnosis codes after claims are submitted

The correct answer is: Only the current year's known diagnoses

The correct option is influenced by how insurers assess care costs and risk while planning for future budgets. Commercial plans allocate funding based on the current information they have regarding patients' diagnoses because this data typically reflects the most accurate and recent snapshot of the patient population's health status. The knowledge of the previous year's known diagnoses helps inform the expectations but does not change the allocation for the current year. Projected diagnosis codes, while they may play a role in planning, are more speculative and do not directly influence the funds allocated for the current period. Audited diagnoses, which occur after claims submission, provide a retrospective look and typically impact future allocations rather than the immediate budget. Therefore, the emphasis on using only the current year's known diagnoses to guide funding decisions is vital for reflecting the most up-to-date and relevant patient health data in resource distribution.