Health Endeavors' Value-Based Care Newsletter


Get Your ACO's Updated 2021 Quarter 2 Benchmark

Book an appointment with Kris Gates to review your ACOs updated benchmark for 2021 Quarter 2. 


While your ACO received an estimated benchmark earlier in the year from Medicare, we have updated that estimated benchmark to provide ACOs with an ongoing snapshot during the year of the Medicare estimate. 

If a client:  Our team will also review HCC recapture rate, HCC not recoded yet this year, AWV and AHU performance metrics.


If not a client:  We need the following files:


2020 Settlement File

2021 Benchmark File

2020 Quarter 4 QEXPU

2021 Quarter 1 QEXPU

2021 Quarter 2 QEXPU 


Importance of HCC Recapture Rate


The hierarchical condition category (HCC) score or risk adjustment factor score (RAF) indicates how sick a patient or population was in the past or is currently. It is also used to predict the cost of a patient or population.


For value-based care organizations (VBC) working to achieve shared savings, the risk score establishes the financial benchmark (or amount of spend allocated in a year) for a patient or population. For example, an average HCC score of 1.2 indicates an average annual cost of $11,240.40 per patient per year. The VBC's goal is to spend on average 5% less than the financial benchmark to achieve shared savings. If the VBC does spend less than the financial benchmark and performs well on quality measure metrics, the organization shares in the savings with the payer at a pre-determined percentage rate.


Using Medicare claims data, we reviewed 72 Accountable Care Organizations (ACOs) data to determine the impact of recapturing HCC diagnoses. Keep in mind an HCC diagnosis is removed (if not recoded) after 12 months. The goal of the HCC recapture rate is to determine the rate at which recurring chronic conditions were recaptured during the year or past years. The analysis indicated:

  • 85% recapture rate is very good as this rate will not result in a downward adjustment of the HCC risk score in 90-95% of the use cases. 

  • 75% recapture rate is fair as it will not result in a downward adjustment of the HCC risk score in about 75-80% of the use cases. 

  • 60% recapture rate is poor as it will not result in a downward adjustment of the HCC risk score in about 70-75% of the use cases.

This also drives home the importance of an annual wellness visit (AWV). The AWV is the clinic encounter in which all diagnoses should be reviewed and coded each year. During other encounters such as an injured foot, the provider team is focused on the injury and not coding all other diagnoses. Thus, the AWV is a critical component of the HCC recapture rate. Our findings regarding AWV and HCC risk score indicated an 85% AWV completion rate resulted in an 80% or higher HCC recapture rate.


It is imperative for the provider team and leadership to understand the status of their HCC recapture rate and AWV rate of completion monthly.


If your VBC is performing poorly on AWV and HCC recapture rate, now is the time to implement a plan for the 4th quarter of 2021.


Retrospective vs. Prospective Attribution

Patient Workflow.png

Over the summer, Medicare ACOs have been considering their patient attribution choices between retrospective and prospective. Retrospective and prospective options both use claims-based algorithms to attribute patients to an ACO if a plurality of qualifying services over a 12-month period are received from a participating provider.


In retrospective attribution, patients are assigned based on care provided during the contract year, and final attribution occurs at the end of the contract performance year (PY). In retrospective attribution, patients who received care from the ACO during the PY are captured in the ACO population.


In prospective attribution, patients are assigned at the start of the contract PY based on claims in the prior calendar year, which allows ACOs to know their defined population and provide care management during the PY.


Retrospective results in a larger pool of assigned beneficiaries:

  • Beneficiaries are only required to be eligible during the performance year under retrospective, while under prospective assignment beneficiaries require eligibility under both the performance year and the assignment period.

  • Prospective doesn’t consider new Medicare patients (newly enrolled during the current performance year) unless patient conducts voluntary alignment. If there is a high rate of new Medicare enrollment in the local market or “age-ins,” the ACO may favor retrospective assignment or conduct robust voluntary alignment.

  • Prospective assignment has a longer period of time in which beneficiaries can lose assignment eligibility due to Medicare Advantage Enrollment. 

However, prospective does allow the ACO to know assignment in advance and does take priority over retrospective.  


Due to the differences in attribution processes, the approaches and resource allocation are different to achieve shared savings:


Regardless of the attribution type selected, to be successful, ACOs need to establish a patient annual workflow for all Medicare FFS patients that includes an annual wellness visit and follow-up visits to:

  • Capture all HCC diagnoses

  • Discuss with the patient you are their primary care provider and to seek all services from you as their primary care provider and not to go out-of-network or use the urgent care or emergency visits for non-urgent care.

  • Complete the quality measures at the annual wellness visit and follow-up in subsequent visits.

  • Complete a medication reconciliation during each encounter and verify the patient is picking up the medications you prescribe using your ACO claims data.

  • Enroll high-risk patients in care management programs for phone interventions between face-to-face encounters.

To achieve shared savings in retrospective attribution the ACO must treat every Medicare patient under the same process to ensure past and current patients that may become attributed during the year are incorporated into the ACO care improvement strategies.


Prospective should follow the same process, however as their population is stagnant during the year, they can implement a more pro-active approach to the high-risk patients as they can identify these patients in January instead of later in the year. Instead, retrospective will have high-risk patients coming into the ACO throughout the year and will be more reactive to those patients as they can't be identified at the beginning of the year.


After implementing a patient annual workflow, it is imperative to track performance targets such as HCC recapture rate, benchmark used, and annual wellness visit completion rate monthly using your claims data.


Using Data to Screen Prospective Participants

While your ACO received an estimated benchmark earlier in the year from Medicare, we have updated that estimated benchmark to provide ACOs with a more recent snapshot as of Quarter 2.


Book an appointment with Kris Gates to review your ACOs updated benchmark for 2021 Quarter 2. 

To request access, you will need a patient attribution list from the prospective participant.

Contact to learn more!


APM Entity Quality Readiness