Risk adjustment coding runs deeper than Medicare Advantage. As health systems increasingly manage patients across several risk-adjusted plans, variation between models makes it more challenging for providers to consistently capture conditions in ways that support both care quality and reimbursement.
Understanding how hierarchical condition category (HCC) context fits into clinical workflows is key to closing risk adjustment gaps beyond Medicare Advantage.
The hidden problem in risk adjustment
Across IMO Health’s analysis of 12.8M patient records, we found $3.04B in reimbursement risk associated with chronic conditions that were missing, incomplete, or inaccurately reflected in patient records. While this risk spans all risk-adjusted populations, many health systems focus their efforts on Medicare Advantage – leaving other risk models under-supported.
For clinicians managing patients with chronic disease, gaps in understanding which HCCs apply to each patient’s risk model create two core challenges:
- Clinical visibility drops: Clinicians sometimes enter visits without a complete view of all relevant chronic conditions in the problem list, even when that information exists elsewhere in the chart.
- Reimbursement suffers: Risk-based plans rely on accurate capture of HCCs and ICD-10-CM codes. When conditions don’t surface within the context of the appropriate risk model, organizations may not receive the resources needed to care for higher-risk patients.
Despite growing pressure to accurately capture HCCs, most electronic health record (EHR) tools remain focused on Centers for Medicare and Medicaid Services (CMS) HCCs, effectively anchoring risk-adjustment workflows to Medicare Advantage alone. For patients covered by the Affordable Care Act marketplace, Medicare Part D, or Medicaid, clinically relevant conditions may not appear in the provider workflow because each model recognizes a different subset of ICD-10-CM codes.
Without clear payer and risk-model context for each condition, even thorough documentation may fail to translate into accurate risk adjustment.
Why HCC context matters beyond Medicare Advantage
Medicare Advantage relies on CMS-HCCs, but other risk-adjusted plans operate under different models. For example:
- ACA Marketplace uses HHS-HCC
- Medicare Part D uses RxHCC
- Medicaid employs state-defined models (ACG, CDPS, CRG, DxCG)
When documentation and workflows don’t account for these differences, organizations may perform well in Medicare Advantage while consistently under-capturing risk across other populations. This results in suboptimal reimbursement and under-resourced care teams; clinical documentation alone isn’t enough if it isn’t aligned to the applicable risk model.
ACCESS and the expansion of risk adjustment
The risk-adjusted landscape continues to evolve. The ACCESS Model, set to launch on July 1, 2026, introduces a technology-enabled, outcome-driven approach to chronic care under Medicare. By shifting payment from volume to value, ACCESS reinforces the need for accurate, context-aware documentation that reflects true patient complexity and supports sustained care delivery.
As margins tighten and more patients fall under non-Medicare risk-adjusted contracts, capturing the right conditions for the right risk model – consistently and with context – becomes essential to sustaining high-quality care.
When EHR workflows conceal the history or relevance of chronic conditions at the point of care, clinicians are left guessing which diagnoses must be recaptured to support an accurate risk adjustment factor score. That uncertainty undermines both clinical confidence and financial stability.
How IMO Health brings risk-model context to the point of care
IMO Health’s problem list tooling surfaces real-time HCC and chronic condition context across multiple risk-adjusted programs, directly within the EHR workflow. This allows health systems to extend risk adjustment strategies beyond Medicare Advantage.
IMO Health’s tooling enables organizations to:
- Recapture previously documented HCCs missing from the problem list
- Uncover additional conditions from unstructured clinical notes
- Align conditions with the correct payers and applicable risk models
As a result, ACA patients surface HHS-HCCs, Medicare Part D patients surface RxHCCs, and upcoming enhancements support Medicaid and ACCESS models. As value-based care expands, IMO Health ensures your strategy works across all risk models – not just Medicare Advantage.
