The Centers for Medicare and Medicaid Services (CMS) requires that insurance plans submit claims using specific coding for Hierarchical Condition Categories (HCC). These categories represent specific health conditions and diagnoses. CMS payments are based on these categories, so proper coding is essential for accurate revenue reimbursement.
CMS typically reimburses a plan based on an individual in average health. Risk adjustment allows a Medicare Advantage Plan to compare one member’s health status against this average.
If a plan submits a claim for a chronically ill individual or one with a preexisting condition, they may likely receive higher CMS reimbursement revenues in the future and possibly even retroactive payments for previously undiscovered diagnoses.
EMSI works with credentialed coding professionals to review your members’ charts and medical records for coding inaccuracies, to improve diagnosis capture and to promote adherence to CMS guidelines.
Maximize your CMS reimbursement revenue through accurate HCC coding.
Find out how EMSI can help