BC Advantage - 2025 Issue 6

Best Practices in Risk Adjustment and HCC Coding: Ensuring Accuracy and Compliance

Healthcare is shifting from a fee-for-service model to a value-based care approach, focusing on quality and outcomes over volume. Risk adjustment plays a crucial role in ensuring fair reimbursement for health insurance plans, enabling them to maintain coverage and access to care for high-risk individuals with higher-than-average medical costs. Under this approach, providers must have a clear, concise, and comprehensive understanding of their patients' health status and medical conditions. This is where Hierarchical Condition Category (HCC) coding comes in. The American Academy of Family Physicians states that the primary goal of HCC coding is to “communicate patient complexity...

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