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Medicare Advantage HCC Codes

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CMS Proposes Major Changes to Medicare Advantage HCC Codes in 2024

The Centers for Medicare & Medicaid Services (CMS) has recently announced comprehensive changes to the Medicare Advantage program, mainly focusing on HCC codes, slated for implementation in 2024. This groundbreaking move is expected to revolutionize how healthcare providers and payers approach risk adjustment and reimbursement strategies.

Understanding the Revisions in HCC Codes

The upcoming changes involve:

  • Comprehensive renumbering and renaming of existing HCC codes.
  • A significant expansion in the total number of HCC codes.
  • Modification in the mapping between ICD-10-CM codes and HCC codes.

These modifications in HCC codes are far from being mere administrative tweaks. They are poised to recalibrate the Risk Adjustment Factor (RAF) scores, which are critical in determining the cost estimates for Medicare Advantage beneficiaries. These scores, based on a combination of demographic data and disease risk assessments, dictate the financial reimbursements from CMS to health plans, with higher scores typically indicating patients with more complex health conditions.

The Impact on RAF Scores

The impact of the CMS HCC Version 28 (V28) model on RAF (Risk Adjustment Factor) scores is significant and multifaceted:

1. Constraining of HCC Coefficients: The V28 model employs a process known as constraining, where related HCCs are assigned similar coefficients. This means that the RAF score contribution from certain conditions, such as diabetes, will remain unchanged regardless of the severity of complications.

2. Lower RAF Scores Expected: Due to these changes, it’s anticipated that RAF scores will generally be lower for many Medicare Advantage beneficiaries. This is because the constraining process standardizes scores across various conditions, potentially reducing the differentiation of risk scores based on condition severity.

3. Reduction in MA Risk Scores: The proposed changes in the V28 model are expected to result in a 3.12% decrease in Medicare Advantage risk scores for 2024. This decrease indicates that the overall risk profile of Medicare Advantage populations may be assessed as lower under the new model.

4. Cost Implications: A lower RAF score generally translates to lower payments from CMS to Medicare Advantage plans, as the payment rates are adjusted based on the perceived risk of the covered population. Therefore, these changes could lead to significant cost savings for the Medicare Trust fund.

These changes underscore the need for healthcare organizations to adapt their risk adjustment strategies, as the way conditions are reported and scored will have direct financial implications under the new HCC V28 model.

RAAPID’s Approach to the New HCC Codes Era

At RAAPID, we are acutely aware of the challenges and opportunities these shifts in HCC codes present. Leveraging our expertise in AI, ML, NLP, and knowledge graphs, our healthcare technology platform is strategically equipped to guide our clients through this new era in healthcare. Our cloud-based Risk Adjustment applications are designed to process structured and unstructured patient data efficiently, ensuring accurate chronic condition extraction and alignment with the evolving HCC codes and RAF scoring system. This capability is essential in assisting our clients to adapt swiftly and effectively to the new HCC codes and RAF scoring criteria.

Gearing Up for 2024

As 2024 approaches, RAAPID is dedicated to staying at the forefront of these developments. Our team continuously updates our platform to reflect the latest changes in HCC codes and RAF scoring methodologies. We aim to ensure that our clients remain ahead in risk adjustment and value-based care, seamlessly adapting to the evolving healthcare landscape.

Stay connected with RAAPID for further insights and updates on how these changes in HCC codes will unfold and how we can assist your organization in this transition period. With our cutting-edge solutions and expert guidance, navigating the new Medicare Advantage HCC codes landscape in 2024 will be an empowered journey for all our clients.


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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.