How to Close Gaps in Medicare Advantage Plans

The Medicare Advantage (MA) program has experienced tremendous growth. This trend is expected to continue in the coming years, as evidenced by the vast scope of options available during the Medicare Advantage 2022 open enrollment period.

On the other side, Medicare Advantage Plans may face service constraints. It's not an effective way, and there are several causes for such discrepancies, but the good news is that they may be addressed with the correct methods and tactics.

 

Gaps can occur when Medicare Advantage Plans do not have strong relationships with provider organizations and medical institutions. It can lead to missed opportunities to work with the care coordination team to prevent gaps from forming in the first place.

 

It is Critical To Keep An Eye on HCC Close Gaps

 

CMS's risk-adjusted value-based payment scheme for Medicare Advantage plans employs the Hierarchical Condition Category HCC Codes, a compilation of diagnoses. The HCC Codes are the most critical determinants of an individual's overall health condition since they highlight chronic illnesses in particular. Each one has its Risk Adjustment Factor (RAF) score. Most HCCs are long-term conditions.

 

Estimating healthcare expenses necessitates collaboration between physicians, coding professionals, and health managers. The over-representation of HCC codes is considered cheating, while the under-representation of HCC codes leads to under-payment for healthcare services provided to chronically ill patients.

 

For leveraging data-driven insights and rules-based rational thinking of structured healthcare data, can the following gaps in medical files are recognized:

 

Diagnoses that aren't recorded:

 

The medical record collection is undertaken on individuals to get unsubstantiated HCC Coding to comply with the Affordable Care Act's standards. Individual health screenings for patients with unreported HCCs emphasize the plan to reduce patients' treatment gaps.

 

Coding Precision:

Health professionals are encouraged to code with as much specificity as feasible. However, coding standards like ICD-10-CM include many diagnoses, some of which are hidden deep inside their hierarchies.

 

Yearly Revalidation Is Must:

Individuals who neglect to follow up on their insurance coverage are not reimbursed, and the same is true if individuals are seen but not handled appropriately while documenting the records.

 

Validation of the Coding Procedure:

 

Skilled coders must discover and translate interface terminology into ICD-10-CM language because it does not correspond to HCC codes.

 

HCC Closing Gaps can lead to more effective payments, enabling insurance companies and providers to be made responsible for the environment in which it operates.