Capturing HCCs at the Point-of-Care: Why Provider Engagement Is Key

The Challenge: HCCs Lost in the Workflow

Providers operate under intense pressure—managing high patient volumes, documentation requirements, and multiple technologies. Even with the best intentions, HCC-relevant diagnoses are often missed.

The industry data illustrates clearly:

• Studies estimate that as many as 20–30 percent of chronic conditions go undocumented in claims data each year, directly reducing HCC accuracy^¹
   

• According to the National Association of ACOs (NAACOS), primary care practices typically miss 8–12 HCC opportunities per 100 Medicare Advantage patients^²
   

• Inferscience reports that provider follow-through on HCC alerts averages just 40–50 percent, underscoring the importance of delivering prompts that fit seamlessly into provider workflow^³

These gaps lead to incomplete patient risk scores, inaccurate health plan reimbursement, and unnecessary dependence on costly retrospective reviews.

Why Provider Engagement Matters

We believe the key to improving HCC accuracy isn’t just by layering on more technology, but by engaging providers in a way that supports their workflow rather than disrupts it. Our Provider Engagement solution is designed to do exactly that:

• Real-time visibility: Providers see suggested diagnoses and coding opportunities during the patient encounter
   

• Contextual intelligence: The system delivers robust AI insights based on clinical documentation, claims, and historical coding datasets
   

• Workflow alignment: Alerts and recommendations appear within existing EHR workflows, minimizing friction
   

• Closing the loop: Providers can confirm, reject, or update suggested diagnoses on the spot, ensuring accuracy and compliance

This approach transforms risk adjustment from a retrospective exercise into a collaborative, real-time process.

Real-World Example

Consider a patient with diabetes who has also developed diabetic neuropathy. Without real-time prompts, the provider may document only the diabetes code, missing the complication. That oversight results in an incomplete HCC profile, underestimating the patient’s risk score and ultimately impacting health plan reimbursement.

But with a dynamic prospective solution, the provider can receive a prompt during the visit to evaluate and document the complication. The diagnosis is confirmed at the point-of-care, ensuring the member’s health status is accurately reflected.

The Benefits of Point-of-Care HCC Capture

When HCCs are captured during the encounter, everyone benefits:

• Providers: Less documentation rework and improved coding accuracy without added burden
   

• Health plans: More complete and accurate risk profiles, reducing financial leakage and strengthening compliance
   

• Members: Care that reflects their true health status, which supports better outcomes and higher satisfaction

Building a Stronger Risk Adjustment Strategy

Capturing HCCs at the point-of-care is not a “nice-to-have,” it’s a necessity. Our Provider Engagement solution equips providers with the right insights at the right time, ensuring diagnoses are captured, documented, and validated in the moment.

As health plans prepare for the transition to HCC Version 28 and beyond, point-of-care engagement will be the cornerstone of accurate risk adjustment, reduced administrative cost, and improved member care.

References

1. MedPAC Report to the Congress: Medicare Payment Policy. Chapter on Risk Adjustment in Medicare Advantage. March 2020.
    

2. National Association of ACOs (NAACOS). Understanding the Role of HCC Coding in Risk Adjustment. 2021.
    

3. Inferscience. 7 Key Insights for Effective CMS HCC Diagnosis Coding. 2023.