Preventing Revenue Loss in Newly Acquired Populations
As health plans expand their reach—through acquisitions, network growth, or the exit of competitors from regional markets—they often inherit large populations of Medicare Advantage (MA) members with incomplete or outdated documentation. This creates a critical challenge: without accurate Hierarchical Condition Category (HCC) coding early on, these members may appear healthier than they actually are—leading to suppressed Risk Adjustment Factor (RAF) scores, inadequate payments, and misaligned care strategies.
In a value-based care environment, the ability to quickly and accurately document chronic conditions for newly acquired populations is more than a compliance requirement—it’s a financial imperative.
Why Newly Acquired Populations Pose Unique Challenges
New populations come with unknowns. Providers and payers may have limited access to longitudinal health records, face gaps in historical documentation, and struggle to determine which conditions are still active and managed. Additionally, these patients often lack recent encounters, making it difficult to validate diagnoses within the CMS payment year.
Key issues include:
Incomplete medical history: Risk-adjustable conditions may have been coded previously but not documented recently enough to be captured.
Missing continuity of care: There’s often no record of whether chronic conditions are still active or being treated.
Disjointed data systems: Records from different EHR platforms or defunct plans can be difficult to reconcile or integrate.
The Role of HCC Coding in Bridging the Gap
HCC risk adjustment coding can standardize risk assessment, but only if the codes are current, clinically supported, and accurately reflect the patient’s disease burden. For new populations, early and thorough HCC documentation can:
Improve RAF accuracy by capturing all active conditions tied to higher predicted costs.
Ensure appropriate funding to support care coordination, chronic condition management, and preventive services.
Support compliance with CMS’s strict rules around date-specific documentation, data completeness, and clinical validation.
Best Practices for HCC Documentation in New Populations
Conduct Initial Comprehensive Assessments
Schedule wellness visits or risk adjustment evaluations early in the plan year. These encounters are an opportunity to confirm or rule out suspected conditions and establish clinical documentation that meets CMS standards.Use AI-Driven Disease Discovery
Tools that leverage Natural Language Processing (NLP) and predictive modeling can surface undocumented chronic conditions based on clues in past medical records—helping providers uncover hidden risk and close coding gaps quickly.Enable Point-of-Care Coding Support
Integrating HCC suspecting software directly into the EHR workflow empowers clinicians to make informed decisions in real time, without disrupting care delivery.Review Historical Data Thoughtfully
While retrospective data can offer clues, only conditions that are currently active and treated should be coded. Unlinked chart reviews or unsupported conditions pose compliance risks under CMS’s RADV audit framework.Focus on Specificity and Severity
Under HCC V28, CMS places greater weight on accurate severity coding. Vague or general diagnoses may no longer qualify, so documentation must reflect clinical nuance and precise coding.
The Bottom Line
Bringing new populations into a health plan or provider network is an opportunity to deliver better care and improve outcomes—but only if the foundational data is right. Accurate HCC coding at the outset helps align payments with patient complexity, supports high-quality care, and protects organizations from future audit risk.
For Medicare Advantage organizations navigating today’s tighter margins and stricter regulatory environment, proactive documentation of newly acquired members is no longer optional—it’s mission critical.
ForeSee Medical’s AI-powered risk adjustment platform helps health plans and provider groups accurately document new patient populations from the start. With real-time coding guidance and disease suspect identification embedded directly into your EHR workflow, you can capture risk completely and compliantly—ensuring stronger HCC performance from day one.
Blog by: The ForeSee Medical Team