Top 2 Challenges Providers Face When Implementing HCC

Quality and transparency are more important than ever in today’s healthcare market. What’s one way to achieve superior quality? Building a data-driven organization using Hierarchical Condition Categories (or HCC). Smart healthcare systems are leveraging HCC to identify and address high-risk patients to their payers and Medicare to adjust reimbursement. Simply put, HCC codes are linked to specific clinical diagnoses that help designate high-risk patients within your population.

Why Are HCC Codes Important, and How Are They Used?

High-risk patients designated by HCC often have complex conditions such as diabetes, hypertension, or congestive heart failure. These patients require more specific diagnoses, thus designating them as people with high touch, high utilization needs. As a result, these patients will require higher levels of Medicare and Medicaid reimbursements to manage their care appropriately.

Designating part of your population as high-risk using HCC codes has additional benefits: It allows the practice to report using these discreet HCC codes and track the most vulnerable patients’ outcomes. When grouping by diagnosis, a healthcare system can develop a registry for appropriate interventions. For example, diabetic patients should have annual wellness visits, retinal exams, and urine protein tests completed. Ensuring these complex patients are given appropriate lab tests and screenings will drive overall improved outcomes and ensure that no patients fall through the cracks.

At CTG, we help healthcare organizations approach HCC implementation holistically by focusing on how HCC can improve high-risk patient management. We can help you implement customized electronic health records (known as EHR) software; analyze existing populations; and plan clear paths forward with roles, responsibilities, and actionable strategies.

Why Is HCC Important?

When physicians think about HCC, it’s easy to focus on the complexity of the codes. However, the benefits of HCC come from understanding that it’s about more than just the codes — HCC is a way to manage high-risk populations proactively to provide a higher quality of care. Not to mention, it’s a great business decision.

HCC scores can directly improve your practice’s overall financial situation, including how much money insurance will get from the Centers for Medicare & Medicaid Services (or CMS), which they can then pass on to the practice. It’s good for the provider because patients who fall into high-risk categories can be easily contacted and properly brought into care management, getting them into treatment sooner and more reliably.

For example, you could query the HCC code for diabetes to determine how many diabetics might require care in your patient community. This data helps you better allocate funding, develop processes to support that community, and generate revenue. It also creates another touchpoint with the patient, ultimately raising their quality of care. Using HCC is a much simpler process than trying to “guesstimate” based on demographics such as age or weight, neither of which is an effective way of diagnosing a population on its own.

Quality is essential in healthcare, and, in today’s market, that quality is achieved by building a data-driven organization able to report positive outcomes for high-risk patients.

Today’s consumer-driven environment demands excellence in health outcomes. Patients know how to research organizations online by comparing public information about the patient experience, community reputation, and more. Potential patients watching your organization’s reputation for quality can have a significant financial impact on your bottom line. Not only that, but Medicare contracts also depend on a quality assessment (as practices are evaluated on clinical outcomes and patient experiences).

CMS uses a five-star quality rating system with little room for error. For that reason and more, HCCs are foundational to ensuring high-quality healthcare with data-driven outcomes. But many healthcare organizations need help navigating HCC documentation and guidelines. Below, we’ll illustrate how HCC coding is used, how it helps healthcare organizations estimate future healthcare costs, and how to address the main hurdles to HCC implementation.

What Are the Obstacles to HCC Implementation?

There are still challenges that healthcare organizations must tackle when it comes to digital transformation. Despite the benefits, some providers still hesitate to use HCC coding routinely. After all, it’s not just about compliance with CMS; HCC codes make it easier to track patients throughout their lives and better understand their medical histories, potential diagnoses, and care regimens. However, there are still two main hurdles on the track:

1. Securing Provider Buy-In

Providers are so busy trying to provide quality care to patients that it can be frustrating to add new technology to the routine. Physicians are among the busiest professionals worldwide, with full workloads of urgent and emergency requests, making them the most challenging population to drive change through.

It’s frustrating for a busy provider to have to adjust or troubleshoot new technologies when every moment in their schedule counts, which results in overlooking important HCC information. Lack of quality training for providers results in high use of nonspecific codes, inadequate documentation, and misuse of alerts, all of which decrease the efficacy of your HCC strategy. HCC code use needs to be easy and actionable in real-time to ensure that codes are applied appropriately by all providers.

HCC codes are a win-win scenario for the patient, practice, provider, and payer. Using these codes drives your practice’s risk adjustment factor (or RAF) scores, which directly determine the amount of funding you’ll receive for higher-risk patients. Getting buy-in from your providers is critical to implementing an HCC strategy that makes everyone’s lives easier and provides better funding for managing high-risk patients.

2. Overcoming Technology Challenges

Healthcare technology can be expensive to upgrade and maintain, and few practices are looking to replace their EHR software. If your practice is particularly behind on technology, it might be necessary to consider some HCC software to assist your providers. A lack of proper HCC tech in the healthcare industry can result in the following:

- Inefficient provider panel management
- Cumbersome patient allocation
- Ineffective problem-list management
- Insufficient patient monitoring or availability of HCC data
- Misreporting your high-risk patient population to CMS (meaning low RAF scores and reduced revenue)
- Lack of outreach for HCC recapture

Thankfully, there’s no need for a totally new system if your current one doesn’t easily assist providers in selecting appropriate HCC codes. Your current system can be upgraded and enhanced to better support HCC codes and the documentation necessary to use them.

Are You Ready to Take Control of Patient Management?

Here at CTG, we are a full-suite solution for leveraging HCC codes to create better patient outcomes and more revenue. We have the technology, software, and support to help healthcare organizations implement their own digital transformations, provide better education, and test everything along the way. Our experts have extensive experience in Epic, Cerner, and other HCC software that helps process those day-to-day responsibilities and workflows with ease.

With CTG’s assistance, you can develop critical metrics for reporting and gain valuable analytical insights into your patient population. We help our clients advance HCC roles in their organizations and streamline workflows to create a seamless connection between providers, practices, and patients.

Find out why more healthcare organizations are choosing CTG for their digital transformations by reaching out to our experts today.

contact the CTG Team