HCC Risk Adjustment Accuracy

Medicare Advantage plans operating under the CMS risk adjustment model receive higher per-member-per-month payments for members with greater chronic disease burden, as documented through HCC codes in the current data submission period. The accuracy of the HCC coding directly determines whether the revenue the plan receives reflects the true complexity of the population it is managing.

The documentation gap is structural. A member with heart failure, type 2 diabetes, and chronic kidney disease may have all three conditions managed actively and documented in their claims and clinical records from prior years. If none of those conditions appear in a face-to-face encounter coded in the current submission period, none of them contribute to the plan's current-year risk score. The conditions exist. The current-year coding does not.

Plans managing hundreds of thousands of members with complex chronic disease profiles are leaving risk adjustment revenue uncaptured not because their populations are not sick, but because the workflow that connects known chronic conditions to current-year coding encounters is not consistently in place. Identifying which members have high-impact HCC gaps is a solved analytics problem. Connecting that identification to the outreach and provider preparation that closes the gap before the submission deadline is the operational problem most plans have not fully solved.

Your care managers approve the outreach. Providers decide what to document.

Suspected gaps, ranked. Diagnoses in claims and clinical records are compared with this year’s encounters, and members are ranked by impact and time left.

Providers see the gap before the visit. For members with a visit booked, the provider’s office gets the open conditions to assess.

Members without a visit are invited. The agent contacts members with scripts your care managers approve, explains why the visit matters and offers times.

The visit is booked with the member’s provider. ZynSchedule books the visit, and the agent follows up until it is confirmed.

The provider assesses and documents. Only the provider decides what is documented. The gap closes when the encounter does.

Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.