The Water Hazard of Risk Adjustment: HCCs from Claims

I love the saying “Golf isn’t a sport – It is old man walking around in ugly pants.” 

Ugly pants aside, golf definitely has its challenges: water hazards, sand pits … other golfers, trees, birds… finding your inner athlete ….  and so does risk adjustment.

In the last six years we have gone from focusing on chart review to launching various versions of member evaluation, but this whole time we’ve been forgetting about HCCs we are submitting from claims. Those claims-based HCCs are the real hazard in our program.  (Chart review may be like the sand trap — open another one and another one; just keeping swinging and swinging and at some point you will move the ball closer to the hole.)   

We’ve all been at the conferences and we hear that on average, 37% of claims-based HCCs fail during a RADV audit. Last week during our Flash Webinar, The Analytics of Risk Adjustment,  we were talking with 43 health plans and we asked the question:

How many of you health plans are filtering your claims – not just for site of service, provider type, and ICDs that trigger a HCC – but also by code confidence?

The Answer: TWO health plans out of the 43 are filtering their claims by “confidence”

The real question we were driving at?  – are you confident this code from claims will be found in a compliant medical record and be documented appropriately enough to pass a RADV audit? Has more the one physician noted this condition? Does this condition look clinically appropriate for this member?

Claims flow in, and submitting them to CMS is like the peaceful water on the golf course.  It looks harmless enough. But when your golf ball goes into the water, you don’t know if it is 6 inches or 6 feet deep.  And you don’t know what kind of danger you are in if you don’t filter your HCC claims-based codes.  

CenseoHealth is now offering CareCurrent, a current-year analytics service that sifts through your claims codes and stratifies them into confidence tiers.  This enables a health plan to make an informed decision about submitting claims-based HCCs before taking further action (whether chart review or a face to face member evaluation) to ensure there are compliant conditions. 

Even if your golf pants are lacking a certain style, you’ll still be sitting pretty with CareCurrent as your Callaway Diablo Edge Driver.  Four!