Question By: To grow in today’s competitive, quality-focused, and highly regulated market, risk adjustment management efforts are becoming more challenging. The growth of MA plans is just one of several challenges health plans face as they aim to optimize patient care while maintaining high-quality compliance standards. As a health plan, you are responsible for ensuring accuracy in your coding practices. As anyone in the business knows, it’s no cakewalk. Risk adjustment coding directly impacts the quality of care provided, revenue, and accuracy of reimbursement for providers. Getting the coding right and understanding how to reduce HCC gaps is essential.
HCC Model Complexities and Risk Adjustment Use
CMS requires that all qualifying conditions be identified each year by provider organizations. Documentation linked to a non-specific diagnosis, as well as incomplete documentation, negatively affects reimbursement. Healthcare organizations that optimize their EMR, data, analtyics, and education can enable better documentation of care for patients with chronic diseases, leading to more accurate HCC risk adjustment coding, and more appropriate compensation for quality care.
Data challenges causing obstructions in risk adjustment
To calculate the reimbursements and the risk adjustment scores accurately, it is important to capture and document comprehensive patient data for the attributed members. However, there is some information pertaining to a member’s health status and risk that cannot be elicited from the claims data alone. For that matter, clinical data also may not be enough to project a member’s lifestyle choices that can adversely affect their health.
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