The Haute HCC Blog: The 2014 Provider’s Guide To Winning With Medicare Advantage


The Haute HCC Blog: The 2014 Provider’s Guide To Winning With Medicare Advantage  

By Holly J. Cassano, CPC, CEO                                  October 10, 2013 

Well October 1st, 2013 marked the one year date for ICD 10 implementation and with that brings the subject of HCC coding for Medicare Advantage Plans in 2014.  

What is at the root of winning with Medicare Advantage Plans – from a provider perspective, the first line of offense (as I like to call it), is shoring up your current documentation habits.  This means that if you as a provider, have current documentation deficiencies utilizing ICD 9, you will carry over these same deficiencies into ICD 10 next year, if left unaddressed.  

What can you do – you can start now, by reviewing your current panels with all the Medicare Advantage Plans that your practice currently participates with and conduct a baseline chart review to capture ALL current Chronic Conditions that correlate to an HCC and/or RX HCC code and ensure that the indicated documentation accurately supports those codes. 

The overall goal of a MA Plan is to ensure “Early detection, provide ongoing care and provide accurate reporting of all Active Chronic Conditions, in order to drive better health outcomes and improved health statuses for Plan members.” 

Risk Adjustment – The Early Years: 

The historical data for Risk Adjustment speaks to the ideology that CMS initially would reimburse Medicare Advantage plans based on a monthly capitation rate, so that the Plan would be able to provide health care services to enrolled beneficiaries. These rates were solely based on demographics.

Risk Adjustment Today:  

Hierarchical Condition Categories (HCC), the current Risk Adjustment Payment Model, is built on a focus driven base of chronic conditions/disease processes with the overall goal being to allocate more CMS dollars to those plans that have an overall higher risk due to a preponderance of sicker members within the Plan or to Plans that specialize in providing care to high cost/high risk populations. The primary focus is on those members who have specific targeted Chronic Diseases and/or high levels of functional/cognitive impairment.

Risk Adjustment today overall is designed to do the following: 

  • Assist Providers by allowing them to provide the highest level and quality of care to members and to be reimbursed in a timely manner.
  • Assist with maximum reimbursement via accurate HCC code capture.
  • Establish a joint focus on overall quality  

The Nuts and Bolts of Reimbursement for MA Plans: 

So we have established that CMS reimburses Medicare Advantage Plans (HMO, PPO, & Private FFS) – CMS reimburses plans based on established and documented Chronic Diseases of members in the Plan.

The majority of Plans look to contract with the state CMS intermediary at a capitated rate where the average RAF score of its members is close to 1.0 and are reimbursed if the disease burden of its members is higher.

The providers in the Plan will share a certain level of risk, generally in the 30% range, but it can be higher depending on the plan and geographic indices.  Sometimes the risk is 100%, if the healthcare entity also has its own MA plan.

Annual Objectives: 

  • Providers understand that RAFs quantify 70 Hierarchical Condition Categories (HCC), which cover 3,000 ICD-9 codes currently.
  • Since the CMS calendar resets ALL Plan Members Chronic Conditions back to 0 every January 1st, it is imperative that each member is seen within the first six months of the New Year by the Primary Care physician,  to re-establish the baseline RAF score on all current disease processes with documentation of HCC codes and reporting them to the Plan.
  • A Plan’s profitability is all about preserving the RAF score.

Annual Realities: 

  • Member Visit  –   10 – 15 % of members go unseen by their Primary Care provider annually
  • Assessment of Conditions –   Incomplete medical history
  • Documentation of Chronic Conditions is Assessed
  • General/generic Descriptions in lieu of a specific diagnosis – Diabetes and failure to include an active manifestation of CKD IV
  • Failure to document active disease processes in the progress note annually
  • Undocumented test interpretations or Diagnosis for RX medications
  • Under Documented Conditions (Amputation status, Drug Dependence)

Complete and Accurate Coding (Specificity)

  • Active condition vs History of a condition
  • Coding for Manifestations

The RIFF with the RAF 

A RAF score will vary patient to patient and provider to provider, depending on the HCC coding and documentation efforts from the provider/ staff.  The RAF score can vary anywhere from 0.6 to 1.7, as the documentation is either supportive or unsupportive for HCC coding.

CMS feels that a RAF score of at least 1.0, is indicative of sick patients/members, when that number is less than 1.0, CMS interprets that information as if the panel for the Plan is healthy.  

RAF Score Facts:

For approximately every RAF score increase of 0.1, means an average increase to a plan of about $1.5 million CMS dollars for approximately every 10,000 members.  However, many factors affect this figure and the negative impacts to a Plan’s CMS dollars are typically a combination of the following:

  • Approximately 20% of previously documented codes drop off annually from a patient’s record
  • Close to 30% of coded and reported conditions are undocumented in the medical record or have incomplete documentation that does not hold up to RADV/CMS Validation
  • Close to $5M is racked up annually in reimbursements to the plan for roughly every 10,000 MA patients
  • If a provider fails to document just one code per month, this can result in negative cashflow of up to $45,000 per provider per year in revenue

(Statistics based on an PMPM of $750.00 with an average RAF score/HCC code of 0.415) 

The Winning Formula for Providers: 

  • Schedule a baseline audit for all practice providers to assess group and individual provider coding patterns
  • Review provider risk scores from plan data
  • Review the median number of diagnosis codes submitted per visit per provider
  • Schedule AWV’s for all members on practice panel for the first half of 2014
  • Re-evaluate chronic conditions every six months
  • Review patient records in advance of visits to update/create active problem lists to aide with documentation at the scheduled visit
  • Follow-up on reported but undocumented conditions
  • Narrow emphasis to improved provider documentation versus coding, so that coding is supported
  • Plans look for well performing providers during Open Enrollment and will guide patients in their direction, regardless of what you are told.
  • Your PMPM is set in increments generally and is gauged on lower MLR’s and RAF scores of 1.0 and higher.
  • HEDIS Bonuses are also driven by documentation and management of Chronic Conditions, so it pays to be pennywise versus pound foolish


A plan only needs to capture those chronic conditions annually for CMS reimbursement, but it is good practice to review these conditions at minimum, every six months to ensure accurate reporting to the plan.  The CMS dollars that are allocated to a Plan are to allow for better benefits and better premiums to members and providers, not just for the Plan’s benefit.

Accurate HCC reporting will ensure the right premium for the patient’s level of severity! 

For more information on Medicare Advantage Plans and HCC coding, please visit Scan Health Plan’s HCC Blog at: 

Tune in to The Haute HCC Blog, with me, bi-weekly at: 

Happy Coding! 


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Holly Cassano

Holly Cassano, CPC, CEO – ACCUCODE Consulting LLC, in partners with Tactical Management Inc., (TMI) Twitter @hollycassano

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