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CMS-HCC Risk Score Accuracy Improves Clinical Outcomes among Medicare Advantage Enrollees

Kenneth R Cohen and Aloke K Mandal

The coding of Hierarchical Condition Categories (HCCs) is tantamount for CMS' reimbursing private plans that participate in the Medicare Advantage (MA) program. HCCs are associated with disease states with higher future medical costs. The CMSHCC payment mode provides MA plans with prospective, monthly, risk-adjusted or diseasebased payments centers, based on the concept that recompense should reflect the disease and related cost burdens of the pertinent population. Much has been written about whether HCC coding creates a financial incentive for plans and their contracted providers to exaggerate the disease status of MA enrollees. In this brief report, one independent physician group with over 20 years’ experience in fiduciary risk assumption not only improved its risk scoring processes but also used these scores as an efficacious population health management tool. As demonstrated, independent of generating further revenue, accurate CMS-HCC risk scores can have an important role in population-based health care delivery and promulgate high-value healthcare.