As enrollment in Medicare Advantage plans grows, healthcare organizations need to be able to predict future healthcare financial resources and appropriate reimbursement. The Hierarchical Condition Category (HCC) risk adjustment model is used by CMS to estimate predicted costs for Medicare Advantage beneficiaries, and the results directly impact the reimbursement healthcare organizations receive. 

The situation in the US with COVID-19 has continued to escalate day by day. Healthcare providers are at the front line of this challenging situation that is impacting the healthcare system in unprecedented ways. In these times of uncertainty, healthcare providers have many moving pieces to worry about, today we will focus on the documentation aspects of the novel coronavirus. 

On March 6, congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act. This new rule allows healthcare providers to bill Medicare fee-for-service for patient care by Telehealth during the current coronavirus pandemic crisis.

CMS Proposed Interoperability Rule: Where is it at?

Despite the fact that revenue from risk-based contracts continues to increase for medical groups of all sizes, motivating providers to fully participate in their organization's risk adjustment efforts remains a challenge for healthcare organization leaders. Because of this, many organization leaders have started looking for different ways to motivate their teams of providers to drive better engagement in HCC Coding & risk adjustment documentation. In our first blog post of this series, we discussed the importance of HCC coding and optimal documentation, its challenges, and the role of the individual provider. 

In February of this year, the ONC and CMS proposed a new interoperability rule that promises to be a game-changer for patients, providers, and software developers like us. Given that the federal government has spent tens of billions of dollars trying to get clinical providers on the electronic health record (EHR) bandwagon with, questionable results at best, it’s a case of better late than never. Here is my perspective as CEO of a clinical decision support startup that stands to benefit from the rule, once it is implemented.

Medicare Advantage plans use Risk Adjustment Factor (RAF) scores to determine patient care expenses. The RAF is therefore a benchmark that enables the Centers for Medicare & Medicaid Services (CMS) to estimate future spending. With higher RAF scores, the amount Medicare pays Medicare Advantage plans for patient care also increases. Ultimately the goal is to improve patient outcome with reduced costs. Risk adjustment can also affect physician income. More recently, Medicare is using the HCC model to allocate costs for patients in Medicare Accountable Care Organizations.

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