This report provides a view of the population that compares individual HCC categories for the current calendar year to the prior calendar year.  For ACO and Medicare type plans that require CMS HCC categories for performance measures, this allows for the plan to determine PCP’s that have not documented HCC incurred in the prior in this year.  Using 2019 as the baseline year will allow the plan to see any HCC categories (gaps) that have not been documented in the current year (2020).  This will allow PCP’s to see, at a member level the care gaps that need to be documented for proper annual reimbursement rates.

Target Audience for this Report

Chief Medical Officer, Medical management/Care Management Department, Physician Relations, Quality Management, Utilization Management.

 

Business Processes Impacted by this Report

Provider relations and the CMO/Medical Director have actionable data derived from this report.   The ability to understand provider’s that have not documented HCC’s associated with the patient in prior years’, for the current year. This is to support providers in documenting their care at a patient level to ensure proper notification of treating the HCC conditions.   Education of providers can be specific and outcome based rather than anecdotal and infrequent.  

Medical Management will focus their member interactions as well as their interface with the providers.   Targeted care documentation for proper annual member reimbursement is informed by this report.

Detail and Definitions

 

Report Filters 

  • Baseline Year – Selecting a baseline year will show HCC Gaps for the following year.

 

Header

  • Members with HCC’s.

 

HCC Gaps by Category

  • HCC Category
  • Total Gaps
  • Percentage (of gaps for this HCC category)

 

HCC Gaps by PCP

  • PCP NPI
  • PCP Name
  • Total Gaps
  • Percentage (of gaps for this HCC category)

 

HCC Gaps by Member

  • Member Number – Links to Member HCC Gap Details
  • Member Name
  • Age
  • Sex
  • HCC Category Gap
  • PCP NPI
  • PCP Name