Medicare Risk Adjustment relies on accurate coding of diagnoses that reflect the true health status of a member. However, most healthcare Providers, justifiably, are more focused on clinical management of their patients than on diagnosis coding. This creates a disconnect between the financial and clinical outcomes for the plan population. Therefore, health plans need to establish targeted risk adjustment programs to ensure that patients’ full risk is captured every year on an ongoing basis.

Hexplora provides a  comprehensive end-to-end solution for prospective and retrospective tracking of HCC conditions, risk scores, and gaps with full out-of-the box support for CMS HCC model. Healthcare organizations and Providers can rely on the accuracy, relevance, and timeliness of HCC scores and gaps for maximizing the effectiveness of targeted intervention strategies.

Our solution assists organizations with the following capabilities:

• Disease Identification and Stratification for targeted care and disease management programs
• Incidence and Prevalence trend for disease conditions and comorbidities
• HCC risk score trends across years at organization, provider, and member level
• Intelligent identification of HCC gaps based on historical diagnoses, specialist visits, and other clinical events
• Risk adjusted cost and utilization trends
• HCC Revenue forecasting and reconciliation
• Full out-of-the box support for CMS HCC model for both current and historical model years

Hex HCC Risk Management Key Features

HCC Gaps and Recapture Rate

HEX HCC Risk Management offers intelligent identification of gaps and forecasts HCC Recapture Rate by comparing patients’ current year diagnoses with prior years diagnoses.

Hexplora leverages intelligent business rules for identifying diagnosis gaps based on the following criteria:

• Missed diagnosis codes from historical diagnosis data
• Potential diagnosis codes that are correlated with specialist visits
• Identification of Chronic and acute conditions based on HCC and non-HCC models
• Potential comorbidities based on identified conditions
• Possible HCC conditions correlated with Quality measures
• Cost and utilization Trends

Cohorts based on Disease Identification and Stratification

Hexplora portal provides a highly intuitive and easy interface to rapidly create member cohorts for targeted intervention based on risk score stratification, disease conditions, demographics, cost, and utilization measures. Users can interactively visualize potential risk score improvement, recapture rates, and premium increases for any selected cohort. Organizations can target their Risk Adjustment campaigns for maximum effectiveness in improving revenue and reducing costs.

Risk Adjustment Campaigns

HCC Gaps and Recapture Rate insights enable organizations to launch Risk Adjustment Campaigns by selecting the appropriate cohorts and specific interventions strategies to resolve HCC gaps.

Risk-adjustment is best achieved in a collaborative model where health plans and providers use a common application. Hexplora offers the capability for Providers to track and monitor HCC risk scores, trends, and diagnosis gaps for their assigned patients directly from the portal or through subscription reports that are automatically emailed to them at provider selected frequencies. Role-based security ensures that Providers can view and access only their assigned patients.

Hexplora’s application offers a guided review process that enables the providers to easily review the diagnosis gaps and validate and confirm the presence or absence of the gaps in order to capture the accurate and full risk of the patient.

CMS Revenue Forecasting and Reconciliation

Our Risk Management solution offers comprehensive capabilities in the area of Revenue Forecasting and Reconciliation. Hexplora provides a monthly forecast of CMS reimbursement based on the latest Year-to-date diagnoses. The forecast reimbursement is reconciled with the actual payment received by the health plan to identify potential increase or decrease in CMS annual adjustments.