TriZetto® Medicare Solutions - HCC Revenue Management

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    Increase revenue through more accurate risk scores.

    Managing Medicare Advantage and Part D plans is no simple task, especially when it comes to Hierarchical Condition Categories, or HCCs. CMS provides health plans with risk-adjusted payments that are based on each member’s HCCs. On average, each HCC is worth $250 per member per month. The more HCCs a member has, the higher the risk score—and the greater your potential reimbursement from CMS.

    But getting accurate claims data can be tough. There are more than 3,000 diagnostic codes that can map to member HCCs, and the potential for error is great. When claims are inaccurate or diagnosis data is incomplete, your health plan may not get fully reimbursed by CMS, and that means a loss of income. That’s where TriZetto can help with medicare solutions.

    Manage HCC risk adjustment more effectively.

    TriZetto’s medicare solutions for managing HCC revenue, the TriZetto HCC Risk Adjustment Manager, can help you improve the accuracy of risk-adjusted payments. This easy-to-use solution gives you the tools to:

    • Assess each member’s morbidity level, based on claims and pharmacy data.
    • Estimate risk scores for members and determine how additional HCCs—suspected or confirmed—might impact revenue.
    • Identify those providers and members who most likely need risk adjustment.
    • Compare coding to determine if risk-adjusted payments from CMS are accurate. Create reports, prepare support documents for audits, and submit documentation to support any additional diagnoses.