HCC Risk Score Calculator 2020

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Hierarchical Condition Category (HCC) Risk Adjustment:

CMS compensates the Medicare Advantage (a.k.a Medicare Part C) Health Plan a premium and this premium is based on underlying health conditions of enrollees in Medicare Advantage Health Plan. The health conditions of enrollees is determined by risk adjustment factor which is calculated using the enrollees's age, sex, disability, medicaid, and diagnosis codes. Hierarchical Condition Category (HCC) is a risk adjustment model that Medicare uses to predict risk of future medical cost.

HCC risk adjustment and coding is a payment model that uses a patient’s health status and demographic information to calculate a risk score in order to establish a baseline for how much it will cost to provide care to that patient. A patient’s health conditions are identified through ICD-10 diagnosis codes submitted on claims which are mapped to HCC codes in the risk adjustment model.

The higher the risk score, the more at-risk and the health plan is compensated annually for providing care to that patient. However, CMS requires documentation of the condition at least once a year. Each January 1, the risk adjustment calendar restarts, and all your Medicare Advantage patients are considered completely healthy until diagnosis codes are reported on claims. CMS regularly conducts Risk Adjustment Data Validation (RADV) audits to ensure accurate HCC coding. If medical record documentation for the patient is incorrect or incomplete, your reimbursement for that patient may be adjusted downward.

[rohitarora]

How do we roll up risk from a member level to a population level? for example if there are 3 members in a population with risk score 0.5, 1 and 10- will the payment be made at a member level (aggregated) or will the risk score be average of the 3 risk scores and then the payment is made accordingly?