THE RISK ADJUSTMENT (RA) PROCEDURE: WHAT IS IT AND HOW DOES IT WORK? The Affordable Care Act (ACA) assures that health insurers do not give low-cost insurance coverage to healthy individuals who seldom see the physician, and that they do not refuse or exaggerate coverage for sick patients. The ACA's idea is to provide inexpensive healthcare insurance to everyone, regardless of how many consultations they require, but there is no easy one-plan-fits-all strategy to follow. With the exception of one thing: HCC stands for Hierarchical Condition Categories, a Risk Adjustment Solution that has been there for a while but gained traction once Medicare Advantage Plans began mandating RAF ratings for coverage. Currently, it's on the minds of every coding executive, as well as every insurance provider. HCC requires a fundamental understanding of Risk Adjustment (RA), and conversely.
THE RISK ADJUSTMENT (RA) P ROCEDURE The Risk Adjustment Solutions help healthcare providers to calculate a risk score based on a patient's demographics and diagnostic procedures, that is a relative estimate of how expensive that patient is expected to be. Since healthy individuals have a lower-than-average Risk Adjustment Factor (RAF) score, insurance costs or funds are
moved from healthy individuals to those individuals who have high RAF scores. Two patients in the very same clinic may have different pricing levels within this payment arrangement. This is dependent on a number of criteria that influence how much risk and work is required in sustaining a condition of the patient. Healthcare insurance companies are concentrating on delivering superior and fairly priced health plans regardless of an individual's health status because of the RAF program and ACA market changes. UNDERSTANDING HCC CODING SOLUTION Hierarchical Condition Categories (HCCs) are used by Centers for Medicare and Medicaid Services (CMS) to remunerate Medicare Advantage Plans depending on their enrollees' health. It adjusts reimbursements based on demographic data and patient health condition to appropriately reimburse for the estimated financial expenditures of patients. The risk evaluation data utilized comes from claims and medical records gathered by health clinics, hospital inpatient encounters, and outpatient care services. This strategy was approved by Medicaid in 1997, and it was implemented in 2004. HCCs are becoming the paradigm for private insurers because of their demonstrated performance in anticipating resource consumption by Medicare Advantage (MA) members, and since the overall tendency is to follow CMS's explanation. CMS-HCC is the new model, formulated on the basis of significant or chronic health issues. Clinicians must document each patient's risk adjustment diagnosis in detail, and this report must be based on clinical patient records data from a face-to-face interaction. Advanced HCC Coding Solutions assist healthcare providers in reporting all diagnoses that affect a patient's assessment, care, and therapeutic interventions, such as co-existing diseases, chronic health conditions, and therapies given.