Adaptation of HCC Coding, Latest Risk Adjustment Solution & Model

The Risk Adjustment Solution forecasts risk scores based on a patient’s demographics and diagnoses. Because a healthy enrollee has a lower-than-average risk adjustment factor score, the insurance premium is shifted from a healthy individual to that enrollee with higher-than-average risk adjustment factor scores.

What are Hierarchical Condition Categories (HCCs)?

Hierarchical Condition Categories (HCCs) are groups of diagnostic codes associated with a specific clinical diagnosis. The risk adjustment model has gained considerable attention in recent times since Medicare Advantage Plans have begun to demand risk adjustment scores for reimbursement. 

As per risk adjustment factors and Affordable Care Act reforms, the health insurers are committed to delivering high-quality, low-cost health plans regardless of the patient's health condition. It is more or less the same method by which patients are awarded a risk adjustment factor score, which is partly based on HCCs.

What is Risk Adjustment Solution & HCC Coding?

Risk adjustment is a technique for predicting healthcare expenditures by equating a patient's health condition to a risk score. The risk adjustment factor (RAF) scores are designed to forecast enrollees' costs of healthcare.

HCC coding is a risk adjustment prediction model that insurance providers utilize to give patients a risk adjustment factor score, in addition to demographic characteristics. Insurance companies can use algorithms to estimate costs based on an enrollees' risk adjustment factor score.

Importance of HCC & Risk Adjustment Solution

As HCCs take advantage of changes from Medicare capitation payments to Medicare Advantage healthcare plans, caregivers who fail to describe pertinent conditions of the patient precisely may reduce Medicare reimbursements.

HCCs decide payment for providers, as per the Centers for Medicare and Medicaid Services' Quality Payment Program. Complex patient incentives under the Merit-based Incentive Payment System (MIPS) and risk adjustments cost component of MIPS are examples of this system.

Modern Coder’s Task

The primary objective of HCC is to provide improved health management and correct reimbursements as per the Medicare Advantage Plan. Medical coders must be aware of the latest rules and informed about HCC to attain this aim. The competent coders will ensure that accurate diagnostic codes are provided together with comprehensive clinical data.

HCC coding, when implemented correctly, simplifies the process, resulting in clean claims and prompt payments.

Conclusion

The latest risk adjustment solution & model has opened a new universe of opportunities for coders and healthcare providers for quick reimbursements.

HCC coding is indeed an integral feature of the healthcare revenue cycle. It must be precise, safe, and efficient to ensure consistent revenue and compliance.