Health Plans – Medicare & HCC Risk Adjustment, ICD-9-CM Coding, Medical Coding Training, Outsourcing & Consulting Solutions

Health Plans

Fully implemented in 2007, the Centers for Medicare & Medicaid Services’ HCC Risk Adjustment payment model modifies member premium based on the presence of ICD-9-CM codes with associated Risk Adjustment Factors. Medicare Advantage Plans that do not adjust to this new reimbursement system risk losing a very significant portion of their revenue.

For health plans, it is easy to see that we have entered an age in which every code counts. In fact, unbilled diagnostic codes discovered through chart review yield approximately $2,500 in incremental annual premium. Yet currently, physician payments are predominantly driven by procedural (CPT-4) coding which remains the focus for most providers, limiting the effectiveness of this risk adjustment method.

Like Medicare, many Medicaid programs are evaluating or have already implemented various risk adjustment methodologies. Many commercial health plans are also analyzing the applicability and impact of risk-adjusted reimbursement on systems, processes and medical loss.

With so much at stake, organizations subject to diagnosis-based risk adjustment are turning to The Coding Source for a full range of retrospective, prospective and compliance programs that assure accurate reimbursement, and address the root cause of lost premiums and compliance risk.

Click here for our HCC Risk Management Solutions.