The popularity of Medicare Advantage (MA) continues to grow, with more than one-third of all Medicare beneficiaries covered by MA plans in 2020. And the Congressional Budget Office estimates that by 2030, 51% of all Medicare beneficiaries will be enrolled in MA plans.

Because MA plans reward providers for the successful management of clinical risk and the delivery of cost-effective care, providers must proactively identify their at-risk patients and deliver appropriate care to ensure optimal outcomes, as well as accurate reimbursement.

Achieving success, however, can be challenging, in part due to the intricacies of risk assessment and the need to comply with often complex documentation and coding requirements. To help providers meet these requirements and qualify for accurate reimbursement, Medicomp has introduced Quippe HCC Risk Optimizer.

The Triple Factors: risk scores, care costs, and HCCs

MA programs rely on the proper documentation of Hierarchical Condition Category (HCC) coding and Risk Adjustment Factor (RAF) scores to estimate patient care expenses and calculate provider reimbursement. To ensure accurate payments, providers must fully and accurately capture a patient’s condition on an annual basis, including complete and specific documentation for all of a patient’s qualifying diagnoses. Until now, determining the correct HCC classification has mostly relied on retrospective, manual chart reviews to identify possible documentation and coding gaps.

Accurate reimbursements for care provided

HCCs are used to calculate risk adjustment factor (RAF) scores, which consider each specific diagnosis for a patient, as well as other factors. Based on RAF scores, capitated payments for each enrolled beneficiary are adjusted to accurately reflect the predicted cost of care for each patient.

Rather than relying on time-consuming and error-prone manual chart reviews, Quippe HCC Risk Optimizer provides an efficient and effective option that empowers clinicians with point-of-care decision support tools, delivering actionable insights during the encounter. Quippe HCC Risk Optimizer integrates with existing EHRs and notifies users at the point of care when coding or documentation gaps are identified. Documentation processes are streamlined to create accurate and complete clinical notes.

Real-time notifications drive documentation and coding accuracies

Consider the possible financial ramifications of inaccurate coding and documentation. A common mistake that providers make is to use diagnosis codes that lack specificity for patients’ actual conditions.

For example, a broad code such as diabetes Type I or Type II is insufficient for the calculation of projected costs and risks. Quippe HCC Risk Optimizer prompts users to document more precisely and note whether a patient’s diabetes is under control, if the patient has other complications, or if there are additional manifestations.

Quippe HCC Risk Optimizer can also prompt users to note when a possible linkage exists between multiple chronic conditions, which can also impact risk score, projected costs of care, and reimbursement.

Better provider workflows

Legacy EHRs were designed to support billing processes and not to facilitate better patient care. These systems rarely include automation tools that support the efficient capture of the required details for HCC classification, which can lead to the incorrect or incomplete capture of chronic condition details.

With Quippe HCC Risk Optimizer, a patient’s full medical history is readily accessible to the physician at the point of care, even when a patient’s chronic condition is not directly related to the current problem. Users have point-of-care dashboard notifications about any conditions or risk factors that are not fully documented or accurately coded, allowing them to make necessary adjustments to treatment, documentation, and coding, while a patient is in in front of them.

Quippe HCC Risk Optimizer works in the background as the physician is documenting the encounter and looks for HCC-eligible codes, prompting users when codes are identified. Clinicians can immediately verify whether specific conditions are present and qualify as a different HCC. RAF scores are also calculated in real time and users are provided details on any additional documentation or treatment requirements that address care gaps or gaps impacting risk score calculations.

To learn more about how Quippe Risk Optimizer can automate the risk assessment, documentation and coding requirements for MA and other risk-based reimbursement models, visit the product page here.