However, the claims data that plans submit doesn't always reflect the morbidity of the membership. There are three primary reasons for this: 1) The condition wasn't reported through a claim for the collection year; 2) a diagnosis that is part of the model was reflected in the claim record; however, based on other claims data, the diagnosis under-reported the condition, resulting in a lower payment; or 3) claims or pharmacy data indicate that there is a condition that is part of the model but it hasn't been reported.

Missing, incomplete or inaccurate claims and diagnosis data can result in underpayment of roughly 10 percent, which could translate to approximately $5 million dollars a year per 10,000 members.

HCC Risk Adjustment Manager helps plans:

• Identify members with chronic HCCs that go unreported year to year and/or who may have additional HCCs based on medical claim and pharmacy indicators
• Provide tools for plans to collect and report additional HCC data to the Centers for Medicare and Medicaid Services in order to realize the appropriate level of revenue for each member
• Track the financial impact of identified additional HCCs
• Obtain information with which to better medical manage the membership. This includes documentation to support audits and identification of providers and members who present the greatest opportunities for revenue management

• Helps plans ensure they receive correct payment
• Identifies members who may have unreported diagnoses
• Identifies providers and members who present opportunities for revenue management