Provider Education is Key to Improving Risk Adjustment Coding Compliance
Lack of collaboration and friction between payers and providers has been a problem for decades. Before high-deductible health plans, most of the behind-the-scenes administrative processes—where much of the conflict resides—were of little concern to consumers. Now that those consumers are responsible for more of their healthcare costs, they’re demanding greater transparency and better service from both their providers and their health plans. When something goes wrong, such as a prior authorization that gets delayed or overlooked, patients suffer the consequences.
Along with the impact on patients, ineffective collaboration between payers and providers can negatively impact revenue for both parties. Hierarchical condition category (HCC) coding, the foundation of the CMS’s risk adjustment payment model, is a prime example.
Risk Adjustment coding provides a holistic picture of a patient’s health to better inform the care plan, lower costs, and achieve the best outcomes. When a substantiated diagnosis code is overlooked, the patient may not be identified as eligible for the risk adjustment program. This can result in less effective care for the patient and lower reimbursement for the payer and the provider.
The Centers for Medicare & Medicaid Service (CMS) uses the Hierarchical Condition Category (HCC) method to calculate risk scores. HCC relies on ICD-10 coding to identify a patient’s health conditions and assign a risk score. Each HCC is mapped to an ICD-10 code. There are more than 70,000 ICD-10 codes. In 2021, for example, the HCC model includes 9,757 ICD-10 codes with 86 HCC categories.1
One of the biggest hurdles to HCC coding compliance is that providers are simply unaware of the scope of risk adjustment coding and its impact on revenue—an impact that is likely to grow as our nation ages. Since older individuals generally have chronic conditions that are more complex and expensive to treat, providers will undoubtedly have a patient panel that includes an increasing number of high-risk patients.
Ways to Improve Risk Adjustment Coding Compliance
The best way to improve risk adjustment coding compliance is to educate providers about its importance and how it works. Providers can be very receptive to education when positioned as a win-win opportunity, as it helps them optimize reimbursement, especially those participating in value-based payments.
A recent survey found that 92% of healthcare providers want better collaboration with payers.2
As part of provider education, payers may want to perform a prospective or retrospective coding review. This analysis provides detailed insight into the high-risk patients that have been overlooked and inaccurate or incomplete documentation. It can also shed light on how much revenue potential was missed and what both payers and providers have to gain through compliance. In addition, these reviews can help prepare both providers and payers for HCC coding audits by the Office of Inspector General (OIG) and the Department of Justice (DOJ) while also preventing “takebacks” for overpayments.
Performing coding reviews and educating providers, however, can be challenging for payers due to the ongoing staffing shortage. A great option is to partner with industry experts who can do the reviews and provider education on the payer’s behalf. Results can be realized faster and with fewer resources. It’s a win-win for payers, providers, and patients alike.
Omega Healthcare can help.
Omega Healthcare is a leading provider of risk adjustment coding services to plans with commercial ACA, Medicaid, and Medicare Advantage lines of business. Omega Healthcare’s risk-adjusted HCC coding creates more accurate documentation of member demographics, health conditions, and health status, which results in better per-member cost calculations and more optimal compensation.
Omega Healthcare’s HCC Coding Review Services include retrospective, concurrent, and prospective reviews. As part of the process, Omega Healthcare provides education for providers within the patient chart. The information includes in-depth detail on the appropriate HCC coding for that individual. This can help providers improve their coding quality and HCC coding compliance while also benefiting the payer through more optimal reimbursement in the future.
- 650 HCC coding specialists
- 5 million member charts coded each year
- 60% average savings on each chart reviewed
- 98% coding accuracy
- Leading provider of HCC coding services for Medicare Advantage plans
Learn more about how Omega Healthcare can help organizations improve risk-adjusted coding and achieve HCC compliance.
 “Risk Adjustment and HCC Coding – A Look at Best Practices,” Meghann Drella, Outsource Strategies International, Nov 11, 2022
 “How Health Plans and Health Systems Can Collaborate to Benefit Members,”Healthsparq, Inc., part of Kyruus, 2021