Risk Adjustment

Because most Medicare Advantage plans still leave millions of dollars on the table because of incorrect or incomplete Hierarchical Condition Category (HCC) coding, plans have made great effort to increase their risk score. The results have been unspectacular in enhancing revenue and quality of care alike.

Most plans rely on two sources for their HCC codes: claims and chart review. This is a disastrous cocktail that guarantees high compliance risk under the looming RADV program and fails to adequately enhance the quality of care delivered to members. These programs are also extraordinary complexity from an administrative standpoint, whether your plan vends these activities or conducts them internally.

There is a better way.

Next Generation HCC Management

A mature program eschews codes generated from claims in favor of those generated primarily by member evaluations. These evaluations (erroneously called "prospective" by much of the industry) are a real-time capture of a member's actual health and risk status. The financial return from these evaluations is so great that most plans will run out of time before they run out of members who merit them.

But more importantly, plans can take the results of this highly actionable assessment and share them with internal medical management, the primary care physician, and the member alike. Now, your HCC program is impacting your RAF score (through the tremendous return these evaluations have), your MLR (through better management of care) and even your star rating (through better service to the member). There is still a role for chart review to capture documentation for already-submitted HCC values, but it should be phased out over time. There is no room for claims based submissions.

Perhaps most importantly, member evaluations can bring your risk adjustment program into alignment with your goals for medical management. HCC management after all, should be a clinical enterprise with a financial implication -- not the other way around.

For more information, please contact us at ghg@gormanhealthgroup.com