Managing Risk with Improved Documentation (DOC)

                         

Managing Risk with Improved Documentation (DOC)

Overview

Hierarchical Condition Categories (HCC) is a risk adjustment model used to calculate risk scores to predict future healthcare costs. The HCC risk adjustment model plays a critical role in all risk-based contracts, including Pathways to Success.

When billed claims do not accurately document disease burden using HCC codes there are 3 major consequences:  
1. The full risk burden and expected costs of beneficiaries will not be accurately captured,
2. Risk Adjustment Factors (RAFs) and financial benchmarks will be lower, and
3. Quality benchmarks will be more difficult to achieve.

As ACOs throughout Michigan improve their HCC coding practices we can anticipate regional benchmarks – both financial and quality – will become more challenging to meet. We must proactively address this challenge by taking on local improvement projects, tracking progress, and sharing learnings. 

Problem Statement

Underrepresented disease burden places POM ACO at risk of missing key financial and quality benchmarks and could result in shared losses. 

Goal

Ensure accurate documentation of disease burden within POM ACO population to manage risk through predictive analytics

Objectives

The Managing Risk with DOC LHS aims to:

  1. Share current practices between QROs to develop an understanding of current initiatives
  2. Identify actionable HCC coding gaps at the ACO and QRO level that impact large numbers of patients
  3. Achieve measurable improvement through local HCC coding improvement initiatives

 

Resources 

Contact
                Kelly Schultz
                kellschu@med.umich.edu