HCC Recapture Rate for Disease Burden, Provider Performance, and COVID-19 Risk: How Prioritization Helps

Medical Loss Ratio During COVID-19 by Evan HetuAn effective and essential risk adjustment strategy includes the prioritization of chronic condition recapture each year. The benefit of prioritizing your HCC recapture rate comes directly from the requirement of re-confirming a diagnosis and treating it. First, it ensures regular contact with clinicians to monitor and manage chronic conditions, overall improving the quality of care. Second, it ensures that fair reimbursement for the cost of care, for health plans who maintain Medicare Advantage, commercial (ACA), or Medicaid product offerings.

Tracking HCC recapture is a critical part of a successful risk adjustment program as it provides actionable population health metrics: uncovering potential gaps in either access to care, care provided, or documentation thereof. Monitoring changes in the metrics allows plans to support their provider partners in setting-up targeted programs to understand and remediate the root cause(s) disrupting care. This, in turn, stabilizes risk adjustment revenue year over year, ensuring care is provided to meet the patients’ clinical needs. Furthermore, if conditions related to HEDIS and Stars are treated and under-documented, or even worse, under-treated, the benefits of tracking recapture, and the consequences of failing to do so, become much more serious.

Because of the impact COVID-19 has had on encounter volumes, there may be no more important time to institute a priority-based recapture program. Lower patient volumes have led to the furlough and closing of primary care and specialist facilities across the country, further limiting the opportunity to treat patients and/or recapture chronic conditions. Health plans tracking and prioritizing their recapture rate and opportunities closely were able to intervene earlier with their most critical members as CMS updates to telehealth launched, facilitating the quick spin up of new care delivery infrastructure to reach patients remotely, helping in the recapture of conditions through telemedicine visits.

Given the importance, I’d like to turn to how to prioritize your health plan’s recapture rate. Note that exactly the attention given to prioritization greatly affects the percentage of recapture you should expect to get.

The following bullets are a starting point to getting an accurate, actionable result.

  • Effective prioritization starts with limiting what makes it into the denominator:
    1. Many relevant HCCs apply to chronic and acute forms of conditions, diabetic coma or septicemia, for example. By accidentally counting acute forms of HCCs, the recapture rate will be artificially depressed.
    2. Similarly, eliminating duplicate instances of chronic condition documentation in cases outside of a regular physician visit, i.e. trips to an emergency department.
  • Be mindful of the hierarchies themselves where appropriate; patients can have multiple conditions within the same HCC category or across categories. Appropriate hierarchical capture prevents accidental submission of all possibly applicable codes, to the detriment of accuracy and compliance.
  • Be sure to incorporate model weighting (and diagnosis modifications) over time.
  • When possible, include multiple years of a condition to improve tracking over time.

Remember, if you limit inclusion of diagnoses which are put into a list of chronic conditions that are expected to recur each year, it’s reasonable to expect a relatively stable HCC recapture rate.

A robust recapture tracking program within a larger strategy of risk adjustment can be what differentiates a payer from their competitor and helps ensure accurate reimbursement to cover the costs associated with treating the member. Given the challenges of COVID-19 faced by health plans, providers, and patients alike, it’s time to recognize how Health Fidelity’s Lumanent Retrospective Review, powered by the most mature, clinically-raised NLP on the market can help, even only in a one-time, second pass scenario for sweeps. That’s only the beginning, as well. As vital as it is, HCC recapture is only one of many steps necessary to ensure a successful risk adjustment strategy. Next time I’ll discuss how to build on that recapture strategy to take your risk program to the next level.