How to identify HCC patients for better care, reimbursement

Tuesday, December 20th, 2016

Hierarchical Condition Categories may be nothing new for medical professionals, but in today's healthcare landscape, identifying and leveraging HCCs is more important than ever.

According to The Henry J. Kaiser Family Foundation, nearly one in three people on Medicare was enrolled in a Medicare Advantage plan as of 2016. That translates to approximately 17.6 million beneficiaries. Accurate coding for these patients can significantly increase reimbursement, and HCCs are an essential piece of the puzzle.

Developed by the Centers for Medicare & Medicaid Services in 2004, HCCs were intended to adjust payments to health plans and providers based on Medicare Advantage enrollee health risk. Comprised of more than 70 coding groups related to serious and chronic illnesses, this risk adjustment model determines patients' Risk-Adjustment Factor (RAF), which in turn directly impacts healthcare provider payments the following year.

"One in three people on Medicare was enrolled in a Medicare Advantage plan as of 2016."

In keeping with the increased focus on high-quality care, HCCs are supposed to make it easier to ensure medical professionals can access and document all pertinent information related to patient conditions and health history. This explains why the HCC model is now being utilized outside of Medicare Advantage plans to assist with reimbursement for both Accountable Care Organizations and the Hospital Value-Based Purchasing Program.

This comes at a time when an increasing number of physicians are reporting financial burdens. According to the 2016 Physicians Practice Physician Compensation Survey, which included 1,095 respondents specializing in multiple medical disciplines, 40.4 percent of doctors estimate that overhead comprises between 41 and 60 percent of their revenue. Meanwhile, 40 percent of respondents reported their income has stayed the same compared to the previous year, while nearly 30 percent said it has decreased.

Clearly, making sure HCC information is correctly captured is not only vital to providing high-quality care but to maximizing reimbursement. Unfortunately, accomplishing this is easier said than done for many healthcare providers.

The following are strategies you can use to better capture accurate HCC data:

Standardize procedures
Organizations must standardize identification and outreach measures, whether they concern capturing data at point of care or filling out forms for CMS submissions. All staff should be educated on the importance of HCCs to both patient care and reimbursement opportunities.

Expand data sources
In order to successfully capture essential data, you must expand where you draw from. Solely using claims data to fill out Risk Adjustment Processing System submissions will not provide a comprehensive view of patient risk.

In addition to claims data, healthcare providers should incorporate information from Electronic Health Records and any other pertinent sources.

"30% of physic​ians say their income decreased from the previous year."

Audit charts
Regularly reviewing charts can help medical professionals identify and fix mistakes that may diminish accurate data reportage. Providers that routinely audit charts are likely to recognize common oversights or gaps in information, making it easier to prevent these errors in the future through targeted education and reminders.

Of course, auditing all charts is a laborious, time-consuming process, so it's important to be strategic concerning which charts take precedence. Using EHR data, physicians can determine which patients are at the highest risk of having charts that contain information gaps. This will often be based on specific conditions.

Utilize proper tools
Coding is the cornerstone of many value-based healthcare systems, including HCC. Tools like Intelligent Medical Objects' Problem IT Terminology make it easy to effectively and efficiently capture and integrate essential data for coding purposes.

Problem IT Terminology integrates a patient's existing history with IMO's Intelligent Problem List and IMO terminology to provide a best-practice user experience for problem and diagnosis management. This translates to improved HCC tracking in both assessment history and problem lists, optimizing reimbursement. Healthcare providers can also count on intelligent prompts regarding unaddressed HCCs.

Additionally, Problem IT Terminology can assist with other essential coding responsibilities, including the specificity of ICD-10 codes.

The proof in the process
IMO recently assisted a client in enhancing its HCC processes. Before the client's IMO installation, its identified high-risk patient population was 1,235. Post-IMO install, that number rose to 1,411 - a 14.25 percent increase.

Before IMO Problem IT Terminology implementation, the client had 900 patients that qualified for an HCC score. After implementation of the IMO system, that number rose to 1,021 - a 13.44 percent increase.

This led to the resolution of 450 chronic conditions, marking a 28.57 percent difference from before IMO's involvement. Meanwhile, the number of chronic conditions identified and added for Medicare Advantage patients rose to 311 - a 41.36 percent increase.

What's more, thanks to the IMO solution, the average time taken to generate information following an encounter with a Medicare Advantage patient that is part of a high-risk population was nearly cut in half.

The importance of identifying and leveraging HCCs in patient care is only likely to grow, making it crucial for healthcare providers to pursue proven strategies and modern tools to meet these objectives.

IMO clinical terminology is the most widely used in the industry - find out why.