Medicare Risk Adjustment Solution & HCC

 Risk Adjustment is used in the Medicare and Medicaid programs to adjust capitated payments to ensure equitable reimbursement for delivering healthcare services and benefits to individuals enrolled in healthcare plans.

Medicare is a federal government-funded program that offers healthcare insurance to people  65 and above to cover their medical expenditures. In the United States, Medicare is also available for some impaired people under the age of 65. On the contrary, Medicaid is a huge federal and state healthcare program covering72.5 million Americans, including low-income strata such as pregnant females, children, needy families, pensioners, and disabled people.

The risk adjustment model of the Centers for Medicare & Medicaid Services (CMS) generates risk scores for Medicare participants by using the Hierarchical Condition Category (HCC) Coding method. It helps in predicting future healthcare costs for participants. The risk adjustment analysis is based on diagnostic information extracted from claims and medical records gathered by healthcare facilities, inpatient and outpatient visits, and healthcare services.

The HCC Coding technique categorizes similar medical conditions based on resource utilization. Higher category risk scores indicate higher expected healthcare expenditures. Healthcare providers who actively take part in the risk-adjusted sector of Accountable Care Organizations (ACOs), Medicare's Hospital Value-Based Program (HVBP), or Medicare Advantage (MA) must employ accurate HCC Coding and documentation.

M.E.A.T is Necessary for HCC Coding

CMS mandates that documentation in the medical record material reflect the provider's strategy for patient assistance or Monitoring, Evaluation, Assessment, Treatment (M.E.A.T) of the disease. The term M.E.A.T. is crucial for accurate HCC Coding and medical documentation. It is described as follows:

Monitor: To keep an eye on signs, symptoms, disease progression, and regression.

Evaluate: To check test findings, medication efficacy, and treatment outcomes.

Assessment: It includes consultation, document analysis, and counseling services.

Treatment: This stage comprises prescription, treatment procedures, and other modalities.

Healthcare organizations must keep in mind that if M.E.A.T. is not reported to establish a diagnosis, CMS will reject the diagnosis owing to the lack of evidence provided by the healthcare provider.

Medicare Risk Adjustment HCC Coding

Higher risk scores or Risk Adjustment Factor (RAF) scores represent patients with severe disease and predicted health costs; while lower risk scores signify healthier individuals. However, the low-risk scores may erroneously imply a healthy population when there is inadequate documentation or insufficient Medicare risk adjustment HCC Coding. In 2020, RAF Medicare scores will be adjusted based on the patient's HCC condition count.

To ease the strain on healthcare providers and coders, healthcare organizations have started to use CMS Risk Adjustment Solution to identify and record particular conditions of every patient in their specified group. The HCC Coding assists CMS in properly and effectively aligning insurance payments to the resource needs of a Medicare Advantage (MA) group.