May 23 2017 | 0 Comments | 219 reads Average Rating: 3.7

3 Ways to re-energize your HCC Efforts – Now

by EXL Healthcare in Risk Adjustment

Hierarchical Condition Category (HCC) codes are used in Medicare Advantage to identify individuals with chronic illnesses and then assign a risk adjustment factor score that figures prominently in determining payment levels. With value-based models becoming increasingly commonplace, HCCs are more important than ever before. The Centers for Medicare and Medicaid Services (CMS), in fact, relies on HCCs to calculate patient financial risk in several programs such as Medicare Advantage, Medicare Shared Savings Program (MSSP) and Merit-Based Incentive Payment Systems (MIPS).

The problem: When healthcare organizations don’t optimally document HCCs, they risk missing out on significant revenue. As such, it’s likely that many health plans are looking to improve their efforts in this realm. Here are three steps your plan can take to improve your risk adjustment data acquisition:

#1: Monitor data trends

Under value based models, the volume of claims and encounter data becomes especially important, as it is used to feed the reimbursement model that payers and providers get paid under. More specifically, organizations need to ensure that they are receiving an adequate amount of data in relation to the size of their member population.

Consider the following scenario. A managed care organization or health plan has 2,000 members. On average, each member has six encounters per year. As such, the organization should count about 1000 encounters each month. If the organization notices a drop in data for a particular month, then there is a need to remedy the situation. For example, organizations sometimes experience a drop in data in the summer months, simply because the staff responsible for sending data is on vacation.

#2: Appoint a data czar

Identifying the problem is just part of the solution. Healthcare organizations also need to ensure that someone is in place to take action. For example, health plans can use a dedicated liaison to work directly with provider groups to ensure that all data is received. This person would focus on monitoring the data trends to ensure that data is received consistently. As such, the liaison could raise a red flag when data levels are low – instead of letting the situation languish for two or three months.

#3: Take action

The good news is that remedying these data drop offs doesn’t always require complicated initiatives. Indeed, a liaison can simply pick up the phone and call provider organization who staff member responsible for sending the data and say, “Could you go back and pull all of your data for members who had a data service in June, and re-send that to me?” And, with one phone call, the health plan will have all needed information – without engaging in complicated chart review or analysis at a member level.

These are three steps that health plans can take to ensure they have the data needed to support HCCs. Can you think of any strategies that healthcare organizations can adopt?

Rate this Article:

Average: 3.7 (3 votes)

EXL Healthcare

Log in to post comments



Arun Rangamani
VP, Payment Services Delivery Leader

Ben Steverman
Chief Technology Officer

David Hom
Chief Evangelist

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

John Pagliuca
Vice President, Life Sciences

Lalithya Yerramilli
VP, Healthcare Solutions

Lesli Adams, MPA (Guest Author)
Director of Population Health Strategy, Oracle Corporation

Linda Pantovic (Guest Author)
Director of Compliance & Risk Adjustment, Scripps Health Plan Services

Mark Feeney
Life Sciences Consultant

Monique Pierce
Vice President, Business Optimization

Nayfe Faillace
Chief Compliance & Privacy Officer

Nicole Stec (Guest Author)
Senior Well-Being Manager, Banner Health

Priyanka Rajkumar
VP - SCIOXpert and Solutions, Analytics

Rena Bielinski
SVP, Strategic Accounts

Rodger Smith
SVP, Payment Integrity

Rose Higgins
SVP & GM, Data and Analytics

Subha Vaidyanathan
VP, Technology and Data Management

Taryn Bevilacqua
Compliance Director


Sign up to receive the latest SCIO news & insights, industry updates, event updates and more, right in your inbox.