In CMS-HCC risk scoring, which patients typically yield higher risk scores and payments?

• A. Sicker patients with more diagnosed conditions and appropriate demographic factors yield higher risk scores and payments.
• B. Healthier patients yield higher scores.
• C. Payment adjustments are random.
• D. Only patient age matters.

Answer: (A)

CMS-HCC risk scoring uses a predictive model that weights a patient’s diagnosed conditions and certain demographic factors to estimate future healthcare costs. The more chronic conditions a patient has, the higher their risk score tends to be, because each condition adds cost weight to the overall score. Age-related factors also push scores higher as patients get older. Since payments to plans are adjusted based on these risk scores, sicker patients with more diagnosed conditions and appropriate demographics typically yield higher scores and higher payments. Healthier patients have lower scores, payments are not random, and age is not the sole factor—other diagnoses and their weights play a crucial role.