Certified Risk Adjustment Coder (CRC)

To enhance revenue, which strategy should a Medicare Advantage Plan employ?

1. Code all diagnoses listed in the patient's problem list

2. Develop a prospective approach for HCC capture

3. Focus on high-risk diagnosis codes only

4. Transfer healthy patients out of the network

The correct answer is: Develop a prospective approach for HCC capture

A Medicare Advantage Plan can enhance revenue effectively by developing a prospective approach for Hierarchical Condition Category (HCC) capture. This strategy involves proactively identifying and documenting patients' conditions that influence risk adjustment. By integrating this into their operations, the plan can ensure that all relevant diagnoses are recorded accurately and consistently throughout a patient's care continuum. This approach allows plans to better align patient care management efforts with documentation practices, which not only improves the capture of risk-adjusted revenue but also enhances the quality of care provided to members. It encourages the continuous assessment of patient health status rather than relying solely on retrospective reviews. Additionally, this strategy can lead to improved health outcomes by emphasizing early identification and management of chronic conditions, reinforcing a cycle of care that is beneficial both for the patient and the plan’s financial health. Other methods, such as only coding all diagnoses in a patient's problem list or focusing solely on high-risk diagnosis codes, may miss broader opportunities for revenue capture because they don't consider the full scope of a patient’s health and the potential for revenue based on both chronic and acute conditions. Transferring healthy patients out of the network is counterproductive, as it undermines the goal of maintaining a healthy member population, which is essential for sustainable revenue in Medicare Advantage plans