Covid-19 on HCC Risk Adjustment Coding – A Year Later

The pandemic presented many challenges over the past year, including stay-at-home orders that hindered access to healthcare. During the first half of 2020, many providers’ offices closed to all appointments except emergencies, which delayed routine and preventive care for millions of people. Statistics from the end of 2020 show that prospective risk scores used to pay Medicare Advantage (MA) health plans are trending lower than forecasted. According to a study by Avalere, “deferral of care during the COVID-19 pandemic is resulting in fewer claims and diagnoses among Medicare Advantage (MA) enrollees, which could lead to a 3%–7% reduction in 2021 risk scores and lower plan payments in 2021”. The increase in deferral of care might change drastically this year as the pandemic is subsiding and vaccine rollout continues.

While we did see a huge reduction last year, health plans and providers now are starting to see an increase in demand for elective and routine care, but according to RISE, “the limited capacity and re-strategizing required to meet that demand may continue to impact risk adjustment scores and revenue-capturing opportunities.” As providers continue to face different struggles as a consequence of 2020, success in 2021 requires important considerations and innovative approaches. As pandemic-driven economic instability continues, both providers and health plans must:

1. Act quickly to attend to the increase in demand
2. Collect data to effectively treat at-risk populations (RISE)
3. Accurately document risk scores (RISE)
4. Better enhance patient and provider engagement
5. Consider implementation of innovative strategies that include technology tools

These considerations can not only better prepare provider practices to be ready for the increase in demand and documentation but also improve risk adjustment workflows, which will lead to better risk scores and maximizing reimbursement.

According to RISE, in order to better your risk adjustment workflows, you will also need to consider operational opportunities. Considerations for operational opportunities include:

1. Leverage pre-submission opportunities. Identify potentially missing or incorrect diagnosis codes at the point of submission—before a claim reaches the health plan.

2. Maximize the impact of chart reviews. The increase in missed or canceled visits means fewer charts are available. Health plans and providers must take advantage of new solutions that help streamline and expedite data access.

3. Apply NLP to risk-adjustment coding. The results of integrating state-of-the-art natural language processing (NLP) and machine learning (ML) into risk-adjustment coding are compelling. In multiple engagements across a number of member populations, the technology has helped increase risk capture by 20 percent-30 percent and elevated the average correct risk category capture to 95 percent. (RISE)

That brings us to the next point: the importance of technology in a post covid world. Technology has helped aid many aspects of pandemic life, we now have Zoom parties, online orders for grocery delivery and more, so why are we not maximizing the use of technology for healthcare documentation as much as we can?

For better risk adjustment coding that follows RISE recommendations, take a look at Inferscience’s HCC Assistant.

HCC Assistant by Inferscience

Inferscience’s HCC coding application helps providers optimize HCC coding and risk adjustment documentation. HCC Assistant is a cloud-based intelligent HCC coding and billing platform which is integrated with major EHRs. The platform utilizes advanced Natural Language Processing (NLP) to analyze unstructured data as well as utilizing standardized vocabularies to analyze structured data in the patient chart. The complex intelligent rules built into the HCC Assistant allow it to find diagnoses that may have been overlooked and represent opportunities to improve the documentation in real-time. Where available, write-back integration enables one-click submission of HCC ICD-10 codes and supporting plan of care documentation back into the patient chart.

To make sure all documentation is reviewed and validated, Inferscience offers an add-on product to work with the HCC Assistant, the HCC Validator. The HCC Validator uses advanced NLP technology to instantly validate HCC codes against MEAT criteria and issues a clear “Pass” or “Fail” grade. Having the aid of an HCC Coding tool such as the HCC Assistant and HCC Validator can facilitate HCC Coding and Risk adjustment documentation to generate results that will drive change for your practice.

If you’re a healthcare provider looking for HCC Coding technology tools, reach out to Inferscience at or contact us at (617) 848 9502.

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