Health Systems
are continually searching ways to find the operating costs accurately. The provider-sponsored health plans and
providers with risk-based agreements need to predict costs to remain
financially solvent. A risk-adjusted
score along with HCC auditing andconsulting services is used that haves patient diagnosis and demographic
information in it.
Overview-
It is found that
The Centres for Medicare and Medicaid implemented a Hierarchical Condition
Categories model to balance the payments to private health care plans for the
health expenditure risk of their patients. The Risk Adjustment Model measures
the disease burden that includes several HCC categories, which are correlated
to diagnosis codes. Again HCC is used as a factor in evaluating the total
performance score under the Hospital Value-Based Purchasing Program.
HCC AUDIT
SERVICE-
The consultants
evaluate claims data extracted for inpatient and outpatient. They prepare
medical record assessment by combining both focused and random samplings. Later
it is used to assess for accuracy and the presence of additional reportable
diagnoses with any codes for documented diagnose.
Need of HCC-
There is an
apparent risk when HCCs are combined with revenue. Some other aspects of HCCs
are there that is needed to consider. Acquiring higher HCC shows a correlation
to an improved case mix index. Outpatient documentation improvements targeted
at better HCC capture lead to optimised inpatient clinical management. This gives high-quality information about a
patient. HCC
auditing and consulting services act as a tool for hospitals to
compare risk-adjusted physician performance and target documentation
improvement opportunities.
Types of HCC model used-
1) The
CMS-HCC model-
This model is
used by the Centre for Medicare and Medicaid Services for risk adjustment of
the Medicare Advantage Program. It addresses a predominately elderly population
and over or those otherwise qualifying for Medicare. Hierarchies are implemented
among related condition categories, so that a person is coded for only the most
severe manifestation among co-related diseases. Under this model CMS will begin
adjusting payments to individual providers for fee-for-service Medicare. These are
expected to be based in part on the HCC-related diagnoses to be documented in
2017 and beyond, under the Medicare Access and CHIP Reauthorization Act
efficiently.
2) The
HSS-HCC model-
This type of
model mainly is maintained by the Department of Health and Human Services to
work with commercial payer populations and covers all ages effectively. Both
the models employ a risk adjustment score to predict future health care value
for enrolled patients. The risk adjustment encourages CMS to pay plans for the
risk of the beneficiaries they enrol. By
risk adjusting program payments, CMS can make appropriate and accurate payments
for enrolled patients with differences in expected costs. Risk adjustment is
used to adjust amount based on the health status and all demographic detail of
patients.
There are
negative financial consequences for lack of accurately tracking a patient's
medical history. The risk adjustment model is used since 2004 to determine
reimbursement for various Medicare plans. This HCC framework is progressively
being applied to numerous healthcare reform initiatives. The Providers should
continually strive to improve their HCC program processes by developing
strategies to mitigate issues affecting accurate reporting. In this regard medical coding, an US based
company is providing best HCC service to enrolled patients.
