Effective Ways of Tracking & Reporting Risk Adjustment Solution for ACOs

 The risk adjustment solution enables Accountable Care Organizations (ACOs) to cost-effectively highlight high-risk patient groups. It calculates reimbursement levels and correctly determines costs under a value-based payment model. 

Effective risk adjustment means improved patient care, lower costs, and higher incomes. It serves as a tool for ACOs to assess their performance, and understand patients’ risk adjustment scores. Organizations are delivering a better quality of care through different risk adjustment solutions and payment models including Merit-based Incentive Payment System (MIPS), Quality Payment Program (QPP), risk adjustment factor (RAF) used by the Centers for Medicare and Medicaid Services (CMS) and insurance providers. 

Role of HCC Coding in Anticipating Future Costs

Effective tracking and reporting are crucial for Accountable Care Organizations to estimate future costs due to high-risk patient groups. The risk adjustment model named Hierarchical Condition Category (HCC Coding) focuses on proper documentation and offers higher payments for sicker patients and lower reimbursements of healthier individuals.

For every patient of Accountable Care Organization, the HCC model assigns a risk score or Risk Adjustment Factor (RAF). Retrospective patient data and clinical diagnoses are used for the calculation of the RAF. ACOs can predict future costs to manage the patient population based on effective tracking reporting and patient RAF.  

Effectively Managing Risk Adjustment within ACOs

Risk adjustment contributes to appropriate health plan payments for beneficiaries with varied estimations of medical costs. To manage beneficiary payments effectively, you have to track diagnostic codes for HCC coding-related claims correctly.

There are some steps that ACOs must take to enhance their tracking and reporting risk adjustment operations. These include diagnosis plans, coding expertise, and advanced technology.

1)       Implementation of Strategies for Diagnosis

The caregiver must document all active chronic conditions along with those illnesses that are related to the patient's recent care. Proper documentation minimizes discrepancies in medical records and ensures better diagnosis. Rather than focusing on risk scores, caregivers must deliver accurate diagnoses. It is important to educate them about the monetary value of diagnosis coding precision.

2)      Hire a Coding Team

Hiring an experienced certified risk adjustment coder is essential to get accurate risk adjustment results. The coding team must understand the ACO’s internal coding standards and risk management of healthcare plans. Technically equipped coding teams can carry out the risk adjustment process effectively.

3)      Utilizing Advanced Technology

Integration of advanced technology such as automation tools, rule-based configuration helps to track RAF scores of patients and high-risk groups. It sets up a smoother workflow and sends customizable notifications to swiftly detect high-risk patients and HCC diagnosis codes. It also helps in managing records by retrieving built-in auditing and tracking tools.