How an ACO Recovered Lost HCC Revenue | Koan Health

In 2023, healthcare organizations across the industry faced significant challenges as the Centers for Medicare & Medicaid Services (CMS) implemented changes to their Hierarchical Condition Category (HCC) model. For one regional Accountable Care Organization (ACO), this transition from version 24 to version 28 threatened to impact their recapture rates substantially. However, through a strategic partnership with Koan Health and utilizing the Koan Health Datalyst^TM population health analytics platform, this ACO overcame these challenges and emerged stronger, achieving remarkable improvements in their HCC recapture performance.

When Change Creates Complexity

The ACO experienced a concerning 10% decline in their HCC recapture rate compared to the previous year's performance. The new v28 model introduced updated coding requirements and altered risk scoring factors, complicating the accurate documentation of patient complexity. These modifications created substantial hurdles in accurately documenting patient complexity, a challenge that resonated throughout the healthcare industry.

The decline in performance highlighted a crucial need: healthcare organizations require innovative solutions to adapt to and address evolving CMS requirements proactively. Without such tools, maintaining accurate risk adjustment and ensuring proper reimbursement would become increasingly difficult.

Building a Data-Driven Response

Recognizing the need for a robust solution, the ACO partnered with Koan Health. This strategic decision proved transformative, offering several key advantages:

‍Early Visibility: Koan Health Datalyst provided crucial insights into v28 HCC gaps well before this data was available in traditional Electronic Medical Records (EMRs). This early access enabled providers to take proactive measures rather than reactive ones.

‍Focused Approach: Through sophisticated analytics, Koan Health Datalyst identified two high-impact areas that would yield the most significant results for the ACO's team: Obesity and heart arrhythmia. This targeted approach allowed for more efficient resource allocation and gap closure efforts.

Data-Driven Decision-Making: The platform's analytics capabilities enabled the ACO to pinpoint specific areas requiring improvement in their HCC recapture process, leading to more strategic and effective interventions.

The transition to CMS v28 posed challenges for our organization, but Koan Health provided the insights we needed to get ahead of the curve. Having early visibility into HCC gaps and focusing on high-impact areas allowed our team to work smarter, not harder. The platform's analytics didn't just help us recover– they helped us exceed our previous performance levels. - Clinical Director, Regional ACO

Transformative Outcomes

The implementation of Koan Health Datalyst yielded exceptional outcomes for the ACO:

‍Rebound in HCC Recapture Rates: The organization achieved a remarkable 12%+ increase in its HCC recapture rate, recovering from the previous decline and surpassing its historical performance levels.

‍Boost HCC Score: Improved average HCC Risk Score by an estimated 2.5%.

‍Proactive Risk Adjustment: Early identification and targeted focus areas allowed the team to close gaps efficiently, positioning them for sustainable success under the new CMS model.

This ACO's experience highlights the transformative potential of Koan Health's population health analytics platform for navigating regulatory changes and achieving operational excellence. Our client has improved its capabilities by accurately documenting patient complexity and ensuring appropriate risk adjustment. Through advanced analytics and a focused approach to closing gaps in care, the ACO has built a strong foundation for continued success in the ever-evolving healthcare landscape. - DT Nguyen, Founder and CEO, Koan Health

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About the Client

Regional ACO managing 200,000 lives across Commercial, Medicare Advantage, and MSSP programs
Non-profit health system serving more than one million patients annually
Nationally ranked and recognized for excellence in safety, quality, and patient experience

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HCC Recapture

How did the ACO identify declining HCC performance?

After CMS transitioned from HCC v24 to v28, the ACO experienced a 10% decline in HCC recapture rate compared to the prior year. The drop highlighted documentation and coding gaps that were impacting risk accuracy and value-based reimbursement.

What challenges did the CMS HCC v28 model change create for ACOs?

The transition from HCC v24 to v28 introduced updated coding requirements and revised risk-scoring factors, making accurate documentation of patient complexity significantly more difficult. Many ACOs experienced declines in recapture rates as a result. For this ACO, the shift contributed to a 10% drop in HCC recapture performance, exposing gaps in documentation and coding workflows that the previous model had not surfaced.

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How did Koan Health’s Datalyst platform help address the new HCC v28 challenges?

Koan Health Datalyst provided early visibility into HCC documentation gaps under the new CMS v28 model. The platform helped the ACO identify high-impact conditions, prioritize outreach efforts, and focus on areas with the greatest opportunity to improve recapture performance.

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What actions did the ACO take to improve HCC recapture rates?

The ACO used Koan Health's Datalyst analytics to identify coding gaps, prioritize high-risk members, and support more accurate documentation of patient complexity. Care teams focused outreach efforts on targeted conditions and implemented more proactive risk adjustment workflows.

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What results did the ACO achieve with population health analytics?

Using Koan Health Datalyst, the ACO improved its HCC recapture rate by more than 12% and increased average HCC risk score performance by an estimated 2.5%. The improvements helped align reimbursement more closely with actual patient complexity under CMS v28.

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How is the ACO sustaining HCC performance going forward?

The ACO continues to use Koan Health Datalyst to monitor HCC gaps, track recapture performance, and adapt to ongoing CMS changes. This creates a more proactive and repeatable approach to risk adjustment management.

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How an ACO Improved HCC Performance with Population Health Analytics

Performance Results