Prospective Activities for Your MA Plan

The real key to HCC management for Medicare Advantage plans is to completely and accurately code patients from the outset.

While it's possible to do retrospective recovery up to 13 months after the close of a calendar year, your plan must wait up to 18 months to see payments that they might otherwise have seen within 6 months (assuming CMS gets the checks out on time, an issue they are currently dealing with). Delaying cash flow by 12 months is not a good idea for any business.

In turn, the key to prompt coding is provider education. Do your providers have an understanding of the entire HCC risk-adjustment process? If not, they may not be doing complete and accurate coding of their patients. Most providers still code based on pre-2004 ideas (i.e. based on the treatment delivered during an encounter, not the patient's overall health status).

In addition, there are at least two activities which your plan needs to perform on a prospective basis:

1. New members should be seen as soon as possible - a new member represents an unknown risk profile for your plan.
2. Each of your members should be seen at least annually. This is because every January 1st, CMS conveniently forgets that a patient has, for example, an amputation or other diagnostic status.

Prospective activities are not hard to manage if you have the proper tools for your provider relations, member relations, or providers to use. Leprechaun provides both physician education and prospective management tools for its clients.