The document discusses the importance of accurate HCC coding in the insurance reimbursement process, emphasizing that risk scores for patients with chronic illnesses are determined by demographic and health data. Proper documentation and timely data capture are crucial for maximizing reimbursement and predicting future healthcare costs. Many healthcare practices are outsourcing HCC coding to improve revenue and focus on patient care.

1. Today, the payment model plays a crucial role in insurance
benefits and reimbursement scenario. Under this model, a
risk factor score is assigned to individuals who have been
diagnosed with a chronic or serious illness based on
demographics or health conditions. High reimbursement can
be obtained only when HCC coding is accurate and there is
proper documentation to capture the complexity of patient’s
condition. HCC coding success is hugely dependent on how
accurately and timely data is captured.
Risk Adjustment Model
HCC coding success is hugely dependent on how accurately and
timely data is captured. It also depends on the proper tracking of a
patient’s care and condition over a certain period of time.
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2. How it works?
Health conditions of a patient are determined by ICD-10 diagnose
that is submitted on claims by the physician. Based on the
complexity of the patient’s condition, HCC codes allow payments
to be risk-adjusted. Future financial utilization and risk is predicted
by the risk adjustment model using a patient’s documented 12-
month diagnostic coding history.
As per the risk adjustment model, demographics and diagnoses
of a patient are used for determining a risk score. This is a
relative measure of how costly that patient is being anticipated to
be. For instance, a healthy patient will have a below-average Risk
Adjustment Factor (RAF) score which means, revenue from the
insurance premium is transferred from health patients to patients
who have an above-average RAF score.
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3. When it comes to the risk adjustment model, payment rate of two
patients in the same practice can differ. There are several factors
on which this is based, determining the amount of work/risk
involved in maintaining the patient’s health.
It is very important to ensure proper HCC capture and proper
claims submission with codes that capture all manifestations of a
chronic disease that a patient has. Since ICD-10 has increased
code specificity along with requirements for detailed
documentation, proper HCC capture has become vital.
Many practices are choosing to outsource HCC coding needs
to a third party because it is helping them get timely revenue.
They are also able to focus on quality care provision rather than
worry about coding.
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4. About 247 Medical Billing Services:
We are a medical billing company that offers ‘24/7 Medical Billing
Services’ and support physicians, hospitals, medical institutions
and group practices with our end to end medical billing solutions.
We help you earn more revenue with our quick and affordable
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Contact:
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Tel: +1 888-502-0537
Email: info@247medicalbillingservices.com
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