How to calculate the correct RAF score for (high risk) patients in risk adjustment?

The advantages of Medicare are impenetrable and overwhelming. However, when third-party payer systems go, it might be your last chance to connect with sustainable practices with autonomy. Many people may tell you what they think you need to know for them to succeed, and this article is all about what you need to know for you to succeed. 

The HCC categorizes the capitation payments to Medicare Advantage plans for the health expenditure risk of the patients. They are generally captured over the course of a year by documenting the highest disease categories for each of the patient’s conditions. Documenting the HCC codes allows payers to calculate the RAF score. 

This post will take you through the importance of the RAF score and how to calculate the high-risk patients in risk adjustment. Let us dive a bit deeper to understand better.


Understanding Risk Adjustment and HCC coding


Risk adjustment alters the healthcare cost coverage based on the patient’s health status. The hierarchical condition category (HCC) codes enhance the ICD-10 codes to document the health status. Every chronic condition is assigned a payment value on patient care with the respective condition. The payments are generally adjusted based on the patients’ age, disability, financial status, and diagnoses. The RAF score adds the risk factors to get the total health status score. Once the equation is completed, the RAF score gets multiplied by the average Medicare advantage patient rate. 


RAF Score – What do you need to know?

The RAF score is the amalgamation of the demographic and disease risk scores. The demographic risk score is based on the patient’s age, community, or medical institution. It also considers the Medicaid disability and interactions with age and gender. The disease risk score is associated with an HCC based on ICD10-CM codes for diagnosis. It may be the interactions between disease categories and disability status.


It indicates future expenses, especially for the shared-risk providers and payers. This metric mainly depends on the budgeting and allocation of resources.

A low RAF score may indicate the population is relatively healthy unless documented poorly or incompletely. The HCCs must be recorded yearly to portray every patient’s RAF score accurately.


Importance of RAF Score 


Understanding the importance of RAF scores helps in accurate reimbursement. An RAF score of 1.00 denotes that patient is expected to use average resources, and if it is above that value, it is considered a high RAF score related to the most complicated patients who need complex care and resources. The accuracy of RAF scores depends on capturing chronic conditions that can correlate with HCCs.


If you came across inaccuracy in the scores and searched for better ways or identified the need for health checks to maintain the risk adjustment compliance and financial projections, here is the checklist that can help you identify the improvements by self-assessing the performance.

Best practices guide to HCC Coding

HCC Risk Score Checklist

HCC coder reliability

Physicians generally depend on the coders for assistance in the documentation. It demands high precision to capture the correct code to determine the accurate HCC RAF score. The process itself is complex. There may be a situation where physicians have no adequate time and resources to determine and assign the correct and complete HCC codes for every patient, which may impact n the overall HCC coding quality. 

The probable solution is connecting with an outsourcing partner with a technology solution that complements the human coders and advanced NLP and AI that prompts within EMR and assists with capturing the most accurate HCC codes based on the documentation.


Medical specificity

HCC documentation should ensure medical specificity, which can be captured and substantiated in the patient records. It helps in avoiding the compliance risk. Lack of medical specificity, HCC documentation does not adhere to accurate documentation, especially in chronic condition diagnoses. Hence, when experiencing issues, this metric should be audited and assessed in detail. A good technology platform with retrospective data analysis capabilities helps in tangible improvements.

HCC risk score and diagnosis

Make sure your HCC RAF score correctly captures and coded diagnoses from the past years. The patient data is pulled from the multiple EHR sources that cover hospital inpatient and outpatient data, leading to crucial information that may be lost due to a lack of data interoperability. If the conditions are not documented appropriately, it leads to low RAF scores and lower reimbursement. A secondary internal risk assessment is always suggested in this case.


Inadequate resources

If there are some issues with the RAF score, it is essential to recheck the need for resources because errors may roll in and end up in huge dollars. It is always suggestible to choose the right partner who is proactive in locating and eliminating the process and system.


Wrapping up

The pandemic had a more significant impact, and the focus was shifted to Ai and other technologies to deliver better health outcomes. Submitting the accurate RAF scores is imperative, but tough to do that the very first time submission. But, it is crucial to attain correct reimbursements and comply with the guidelines.

We help you strengthen the processes with AI technology expertise and experience with top-notch risk adjustment coding professionals. We provide multiple options to improve your current processes and accuracy and correct results in RAF Score and HCC coding.

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