January 30 2018 | 0 Comments | 209 reads Average Rating: 3

Proactively Ensure Your Documentation Practices Support Your Bottom Line & Quality Goals

by Rose Higgins in Risk Adjustment

The Medicare Share Savings Program (MSSP) enables providers to assume value-based risk on care delivery for defined populations. Based on a value-based care model that rewards healthcare organizations for improving outcomes, the Shared Savings program promotes accountability for a patient population; coordinates items and services for Medicare fee-for-service beneficiaries; and encourages investment in high quality and efficient services.

As such, organizations participating in MSSP have quite a bit of work on their plate. And, they often focus keenly on reporting quality and utilization benchmarks. But organizations need to do much more to ensure their financial house stays in order so they can continue to deliver high quality care to their patients. Indeed, to succeed financially, MSSP organizations need to optimize payment on a variety of fronts to offset any potential losses. Proficient hierarchical condition category (HCC) coding can help organizations achieve financial success, ensuring that they will get paid for the services delivered and are able to appropriately track and measure network performance. More specifically HCC coding recapture can help organizations ensure that they don’t miss revenue opportunities that they might have missed the previous year and that they proactively identify opportunities throughout the year to ensure coding accuracy. In some cases, HCC coding recapture can help organizations recapture revenue to offset any unexpected deviations from your planned ACO quality and utilization performance (potential penalties).

HCC coding recapture enables ACOs to:

  • Ensure patients receive the right care based on current conditions
  • Identify & reduce variation in provider coding practices
  • Ensure chronic conditions are appropriately documented each year
  • Develop suspect lists to identify patients & providers with likely documentation errors
  • Address provider variation patterns through active outreach and dialogue
  • Create a single view of coding and patient risk across all payers

HCC coding recapture is a time- and labor-intensive endeavor. Using a risk adjustment analytic solution, however, can help. In fact, one Medicare Advantage organization with 68 thousand patients used this tool to close 38% of reimbursement gaps for chronic care patients. By doing so, the organization recovered $24 million in reimbursement in just one year. Additionally, a provider group, participating in an MSSP ACO, found between $1-12M in potential revenue recapture opportunity. The organization discovered variation and opportunities to optimize coding practices across several key areas in which the organization would realize a strong return by allocating efforts to improve outcomes. What’s more, another provider organization seeking to increase visibility across populations and its 850-physician network projected that it could potentially save up to $22 million reducing variations in coding capture. (See chart below).

(Fig: 1) Projected opportunity for provider organization that serves 1.6 M Medicare Covered Lives

What are some of the coding recapture challenges that your organization is currently struggling with? If you are interested in learning more about how SCIO can help with its HCC Coding Recapture as a service, then view our infographic and contact us here.

Also, don’t miss our upcoming webinar (Hosted by HealthLeaders Media) where Scripps Health Plan Services will demonstrate how their focus on risk adjustment practices and quality improvements has driven strong return their organization and their patients: Key Levers to Manage the “Risk” in Your Risk-Based Contracts

Rate this Article:

Average: 3 (2 votes)

Rose Higgins
SVP & GM, Data and Analytics

With over 25 years in healthcare, Ms. Higgins brings considerable experience and expertise in working with both payers and providers in addressing the challenges of a changing healthcare landscape.

Read full profile and other posts |

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.