Throughout the pandemic medical groups have seen patient volumes and elective services decline, causing significant decreases in revenue. This has forced groups to make tough decisions on staffing and re-focus on revenue generation and collections. For groups participating in value-based care models and Medicare Advantage plans, improving the accuracy of HCC coding can have a profound impact on their revenue with minimal organizational disruption.
Who generates revenue in your organization?
Healthcare organizations typically believe that their revenue comes only from their physicians and other clinicians, and from ancillary services such as imaging, on-site pharmacies, and labs. Other employees may be necessary in supporting roles, such thinking goes, but their salaries and benefits are business expenses that must be deducted from the bottom line. Given the rapid and continuing growth of Medicare Advantage and value-based care models, it’s time to reconsider these assumptions and add another group of revenue drivers to the list. That group is HCC coders.
Why are HCC coders important?
Understanding how HCC coders help organizations achieve significant and sustainable increases in revenue begins with understanding how healthcare organizations make money under risk-adjustment contracts that lie at the heart of value-based care.
Under these contracts, payers use a patient’s diagnosis codes (which roll up to HCC codes) to determine their RAF score. Sicker patients have higher RAF scores. Each patient’s RAF score determines the amount of money allocated for patient care—and how much money your organization is paid to provide care for that person. If a RAF score is too low—that is, if it inaccurately indicates the patient’s health is better than it is, or fails to capture the complexity of one or more conditions—you won’t receive enough money to cover the cost of care that patient requires.
Since insurance companies don’t have access to patient medical records, HCC codes are the primary benchmark payers use to calculate payments. To ensure the most accurate RAF scores, it’s critical that your claims include the HCC codes with the highest applicable level of specificity to communicate a patient’s health conditions—especially for patients with chronic ailments.
As groups across the country are making tough decisions, we should think of HCC coders as revenue generators. Without them, you may miss out on significant reimbursement from value-based contracts.
How do HCC coders drive revenue?
While working with a customer recently, we conducted an analysis of five high-volume HCC conditions: diabetes, depression, obesity, chronic obstructive pulmonary disease, and congestive heart failure. Evaluation of the HCC capture data showed that 24% of patients seen by a provider did not have their condition recaptured in 2019.
This directly results in lower member payments, as CMS assumes that patients no longer have these conditions, and therefore no longer require the appropriately adjusted member cost allocation.
Proper HCC coding is complex, and your physicians cannot do this alone. Most times, the physician has done the good work in addressing the underlying HCC condition, but simply didn’t manage the coding complexity well enough—the codes didn’t match the care. The best way to correct this problem and to improve the accuracy of your HCC coding is to support physicians with dedicated HCC coders.
Adding HCC coders to your payroll isn’t just an operating expense—they’re revenue generators.
The additional money they identify through chart and coding reviews significantly exceeds the cost of their salaries and benefits, resulting in a dramatic and measurable ROI for the healthcare organization.
How to increase coder productivity
HCC coders help you capture HCC codes, but hiring a team of coders to support physicians can be cost prohibitive. In a time where you need to do more with less, incorporating automation technology can help with productivity and help you get more out of your investments.
One large medical group in Indiana used a single HCC coder and HCC coding software to find gaps between the physicians’ robust documentation and insufficient HCC coding. This combination lead to the identification of an additional $504,220 in RAF value in less than two months.
THE BOTTOM LINE:
In this challenging environment, groups need to do everything in their power to survive and thrive. While everyone appreciates this, many doctors feel overwhelmed with demands and requests for their time and attention. The good news is that incorporating HCC coders and an HCC coding review process improves revenue with a minimal provider disruption. Delivering a dramatic ROI with minimal impact on providers is exactly what’s needed in times like this.
