How network optimization can help improve your ACO performance
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Hierarchical Condition Category (HCC) coding is a risk adjustment model that uses a patient’s demographic and diagnosis information to generate a risk score that represents the patient’s degree of illness. A patient’s HCC score offers both clinical and financial value as it reflects the patient’s illness burden and can be used to estimate future expenditures for patients.
For ACOs, accurate HCC coding is essential to properly capture risk, improve patient care, and increase shared savings. HCC coding is used in risk adjustment calculations for both Medicare Advantage plans and the Medicare Shared Savings Program. For MA plans, premiums are set based on HCC scores. The higher the HCC score for a patient, the more the health plan will be compensated to care for that patient. For MSSP populations, a higher HCC risk score equates to a higher benchmark for expenditures. Therefore, proper HCC coding is critical to ensure that ACOs are reimbursed adequately and held to an appropriate spending benchmark.
Disclaimer: Any HCC efforts should be carefully reviewed and discussed with your ACO’s compliance officer. Koan Health does not recommend implementing initiatives that may encourage providers to engage in fraudulent “upcoding”. We recommend that ACOs focus their efforts on ensuring their documentation is complete and accurately reflects the conditions that providers are currently monitoring, addressing, and treating.
The HCC Scoring module of Datalyst features analytics to help organizations improve HCC accuracy and increase coding productivity. Specifically, the HCC module of Datalyst indicates how well HCC codes are being captured within a given population year over year. Clients can track important HCC metrics (score, potential gaps, recapture rates) at the organization, population, group, provider, and patient levels. Clients can easily identify the providers and groups with the greatest number of potential HCC gaps as well as the HCCs that are most commonly missed. The insights available in Datalyst can help organizations plan effective initiatives and evaluate their redocumentation success.
Datalyst also provides actionable patient-level data including each patient’s HCC gaps and severity changes, as well as pertinent details for each gap such as the last visit that HCC was coded and the specific diagnosis code that triggered the HCC. This level of detail enables consistent, accurate, and complete documentation. Please refer to the Help Guide in Posts for any questions related to Datalyst functionality on this topic.
This sample use case describes how Mary Washington Health Alliance (MWHA) used Datalyst to develop an activity-based incentive program that improved their HCC accuracy and quality performance. Their “greensheet” initiative encourages AWV completion, care gap closure, and HCC redocumentation. Mary Washington’s success with their greensheet initiative provides an instructive example of how one ACO was able to meet their HCC, AWV, and quality goals in one targeted initiative.
Mary Washington Health Alliance (MWHA) is a clinically integrated network that was formed through a joint venture of community providers and Mary Washington Healthcare. Starting in the Medicare Shared Savings Program in 2015, and later moving to the Next Generation ACO model in 2018, MWHA has proven to be successful in managing costs and improving the quality of care to their patients.
To be successful in value-based care, ACOs must achieve sufficient quality performance and be held to a fair expenditure benchmark. MW saw the Annual Wellness Visit (AWV) as the perfect opportunity to address both of these imperatives. MW leveraged the Annual Wellness Visit to implement a streamlined process for providers to capture the severity of a patient’s illness via HCC documentation and to close quality gaps.
MW designed this initiative because they suspected that they were not accurately capturing the risk of their population via HCC coding and recognized the significant implications this has on their expenditure benchmark. Mary Washington’s primary goal going into the initiative was for the majority of their patients to receive an Annual Wellness Visit. They saw this as the best way to ensure that their providers were getting an opportunity to check in on their patients and close any relevant quality and HCC gaps.
MW produces one greensheet annually per patient and distributes them to PCPs at the beginning of the year for the provider to complete during the patient’s Annual Wellness Visit. The greensheet consists of two parts - an HCC coding portion and a quality gaps in care portion. The HCC coding portion of the form is specific to the patient at hand and lists the top five most impactful HCCs for the patient along with the condition’s billing history, all pulled from Datalyst. Since many of the quality care gaps are widely applicable across MW’s population, they chose to keep the care gap portion of the greensheet the same for all patients.
To complete the HCC portion of the greensheet, providers must indicate whether the condition is still applicable, whether they addressed the condition, and whether they billed for it. Providers return the greensheets on a quarterly basis and the MW chart abstraction team audits a random sample of each provider’s greensheets to ensure that the greensheet matches the medical record and that the provider billed appropriately.
MW providers receive a direct financial incentive for each completed greensheet, which is adjusted based on the provider’s compliance assessed via audit. Importantly, MW incentivizes providers for accuracy, not increases. For example, if the provider indicated that a specific HCC was no longer relevant to the patient, they were still incentivized. Therefore, MW made it clear that there would be no benefit for providers to upcode and that they should only bill for conditions they addressed during the visit, which was verified during the audit process.
MW has experienced high provider engagement with this initiative, with 95% of PCPs participating and an average of nearly 200 greensheets completed yearly per provider. The direct financial incentives make it clear exactly what the provider needs to do to obtain the incentive while the opt-in nature of the program retains physician autonomy. Additionally, MW chose the packaging of the AWV for this program because the AWV is structurally designed for documentation and is a Medicare reimbursable visit. All of these factors were considered and chosen to ensure that providers would benefit from the program and that it would not add unnecessary burden to their workday.
MW used Datalyst in numerous ways throughout the lifecycle of the greensheet initiative, from its development to the evaluation of its success. First, Datalyst was used to determine PCP attribution. Accurate attribution is critical for any activity-based incentive program with providers. MW knew they could trust Datalyst to provide accurate attribution and prevent any foundational issues that could have impeded the success of the initiative.
Additionally, MW used Datalyst to populate the specific demographic and HCC gap information on each patient’s greensheet. Pulling in the HCC codes for each patient from Datalyst served as a reminder for the providers, letting them know which codes they billed last year so they can check if they are still applicable. Datalyst also offers the providers an expanded view of their patients’ HCC and condition history. This encourages conversation on conditions that may go overlooked or that the providers may not even know the patient has. MW found this enhanced visibility into the patient’s health from Datalyst to be extremely valuable.
Lastly, MW continuously uses Datalyst to assess their HCC opportunity at large and to evaluate the success of their HCC recapture efforts.
MW has seen tremendous success with their greensheet initiative which they began in 2017 and have continued every year since. As mentioned above, MW’s goal was for the majority of their patients to receive an AWV each year. MW has been able to meet and exceed this goal each year since the start of the greensheet initiative, even throughout the pandemic. Specifically, as a result of the greensheet initiative, MW saw a 144% increase in AWVs and a 36% increase in HCC count per member from 2017 to 2019. Additionally, MW continues to see impressive increases in quality scores, especially for measures that were incorporated into the greensheet. Ultimately, Mary Washington’s experience demonstrates how one ACO increased beneficiary AWVs and maximized the benefits of these visits specifically to improve HCC accuracy and quality performance.
