Risk-Adjusted Reimbursement (HCC)

Risk Adjustment HCC Best Practices
MARSI’s expertise in the original risk-adjusted reimbursement models, MS-DRGs, APCs, and APR-DRGs positioned us uniquely for this relatively new risk-adjusted model called HCCs. Early on, it became obvious that our innovative programs would work equally well in HCCs.

The problems with HCCs are almost identical to the problems with the more seasoned risk-adjusted models: physician documentation, diagnosis coding rules, overcode potential, even larger undercode potential, physician training, and a process to continuously train physicians and other providers. We have been doing that for decades.

The greatest obstacle is that most codes come from the physician office, where staff and providers are not familiar with the necessary documentation, coding, and coding rules that are required for Risk Adjustment.

The system is still relatively new and most physicians and coding staff don’t understand it, clearly… That is a minus.

The biggest problem is that most codes come from physician offices. The physicians have not been well trained, their focus is not on documentation coding, yet they are the ones coding most of the charts. There is enormous inaccuracy with the attendant risk of non-compliance through overcodes and an even greater larger risk of revenue loss through undercoding. Non-compliance could result in legal problems that impact the physician and his/her practice and also be detrimental in documenting the best quality care to the patients they serve.

The need for physician training, improved documentation, auditing, coder/auditor training, a query process and Continuous Clinical Documentation Improvement is even greater than we had seen with the other programs.

We offer risk adjustment coding, auditing, coder education, physician-led provider education, and best practices that reduces compliance risk and ensures risk score accuracy. We work with plans, provider groups, and individual physicians.


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