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RAF Score Concerns? ECLAT’s 4 Point HCC Risk Score Checklist Can Help

Posted By ECLAT Health Solutions

For Shared-Risk Providers and Payers, RAF Scores are a critical indicator of future expenses.  This metric is relied upon for budgeting and resource allocation, two considerations that are constantly shifting during the unpredictability of the COVID pandemic.

What is an RAF Score?  A Brief Overview

RAF Scores are assigned based on the patient’s diagnosis codes and map to a Hierarchical Condition Category (HCC) and demographic factors.1  In the Risk Adjustment sphere, a score of 1.0 is used as the average baseline to determine an individual patient’s risk.  Patients with a lower score are considered healthier and gauged at a lower risk.1  When the Centers for Medicare and Medicaid Services (CMS) issues a lower reimbursement for healthier patients, they are basing it on this risk adjustment score.

Patients ranked higher on this scale are reciprocally considered to be at higher risk, and the medical community is predicting that their treatment will be more expensive.1  A patient with an RAF Score of 1.30 for example is being projected to cost 30% more to treat than the baseline average.  If a patient has a condition like Congestive Heart Failure (CHF), their RAF Score will be approximately 2.0 - twice as expensive as a patient without it.

Many of the healthcare industry’s financial projections and annually recurring federal program reimbursements are extrapolated from the information that these HCC Risk Scores provide.  Accuracy is critical especially if multiple HCC categories in need of risk assessment apply.  Poor quality coding creates inaccuracies and exposes providers to the risks of potential loss of revenue and of misallocated resources.

If you’re experiencing inaccurate scores and have found yourself searching ‘​​how to get the right risk score’ or if you’ve identified the need to perform a health check to maintain risk adjustment compliance and financial projection accuracy, our team has prepared a checklist to self-assess your performance and identify improvements.

Risk Adjustment Coding Self Audit: 4 Areas of Potential Concern

1. Are your Providers and HCC Coders Overburdened or in need of Training?

Physicians frequently rely on coders or provider educators for documentation assistance.  This demands the highest level of precision to capture the right code assignment to determine the correct HCC RAF Score.1  The process itself can be remarkably complex.  If you sought out this blog or read this far, perhaps you are already noticing indicators such as lowered reimbursements or rejected codes.

In the COVID era, hospitals and health systems nationwide are seeing frequent physician burnout.  Physicians already worked intensive hours even before the pandemic to ensure valuable patient care.  This condition has only been exacerbated by the events of the past two years.  It is common for physicians to have neither the time nor adequate resources to determine and assign the most accurate and complete set of HCC codes patient by patient.  This also means that, unless steps are taken to combat this, HCC Coding quality can easily decline as the scale increases.

The best practices recommended by our team are expanding your scale and increasing your capacity with both an outsourcing partner and a technology solution that complements human coders, employing advances such as utilizing technology with NLP/AI alerts and prompts within the EMR to assist with capturing the most accurate HCC codes based on documentation.

Skilled coding talent can use both the contextual and clinical information of a physician's documentation to perform comprehensive HCC coding assignments. Expert, certified risk adjustment coders ensure that healthcare providers are fully compliant with CMS guidelines and are consistently achieving accurate reimbursements.  However, it is vital to make use of not just the most experienced professionals that you can but also to support the human element with an applied technology solution.

2. Does your HCC Risk Adjustment Coding lack Medical Specificity?

HCC documentation requires the highest degree of specificity to be captured and substantiated in the patient record1 to avoid compliance risk.  Issues caused by a lack of medical specificity can arise when HCC documentation doesn’t adhere to correct documentation.2  This is especially true for patients with chronic condition diagnoses.3  Therefore, when experiencing issues, this metric should be audited and assessed.  Proper procedure requires that an assessment be performed at every patient encounter to reflect in the calculations for the risk adjustment factor for that particular year.

To facilitate this, our experts recommend utilizing a technology platform with retrospective data analysis and summarization capabilities at your fingertips to help make tangible improvements to encounters documented.

3. Is your HCC Risk Score based on All Diagnosed Conditions being Correctly Reported?

Another key area of inspection is whether or not your HCC RAF Score is extrapolated from correctly captured and coded diagnoses from the previous year(s).

Missing additional diagnoses results in a loss of reimbursement opportunities that leave revenue on the table.

While simply omitting additional issues may appear unlikely at first, patient data is often pulled from multiple electronic health record sources, including hospital inpatient, outpatient/physician, etc., which can lead to vital information falling through the cracks or being lost due in part to lack of data interoperability.

If conditions go undocumented, the patient can be incorrectly marked as healthier than they are and given an unjustifiably low RAF score which then returns a lower reimbursement than you’re due.  This is why performing a secondary internal risk assessment review to compensate is always a recommended best practice.

4. Do you have the Bandwidth to Keep Up with the Scale of Necessary to complete your chart reviews?

If you’re experiencing RAF Score issues, it’s likely that your team doesn’t have the time or resources to locate the source of errors.  This is common, and you are not alone.  However, left uncorrected, these errors can add up to large dollar amounts over a population.3  Therefore, choosing a partner who can proactively locate and eliminate these process and/or system inefficiencies is vital to HCC Risk Score health.

To help you compensate and course correct, our experts have put together a checklist of common error zones to track when analyzing your HCC Risk Adjustment Coding efforts.  To ensure you are generating the right RAF Scores, examine the following potential pitfalls that are otherwise easy to miss when time is limited: 

  • Attributes that make a document a valid CMS face-to-face visit.
  • Are your status conditions documented each year?
  • The diagnosis code does not match the narrative description of the clinical documentation. 
  • Chronic conditions that meet the criteria (active/PMH) may be unreported.
  • Coding is not to the highest level documented (i.e. linking statements such as diabetes WITH hypertension WITH diabetic neuropathy).
  • Obsolete codes may have been used (click here to stay on top of new and retired codes for FY 2022).
  • Heavy reliance on problem lists that lack specificity or include patient conditions that are no longer active.

A partnership with ECLAT not only resolves Risk Adjustment issues and supports your efforts with solutions and technology but also offers on-call physician education at your fingertips to improve your processes and guard against future errors.  Flexibility, accessibility, and training are among the most valuable assets a partner can offer when the need for clarifications arises.

Achieving the Right HCC Risk Scores with ECLAT

Achieving and submitting accurate RAF Scores the first time is a crucial component of providing exceptional patient care, attaining the correct reimbursement and staying compliant with reporting guidelines.

A recent 2022 Analysis emphasized how the pandemic has shifted the focus of healthcare to integrating new technologies and AI to deliver better health outcomes to their populations.4  Apply the same technological approach that is bettering health across the country - explore how our ever-innovating tech solutions can impact your ongoing risk adjustment efforts.

ECLAT’s team strengthens your processes with AI-supported expertise, certified risk adjustment coding professionals and a unique in the industry 3-Tier Quality Assurance process.  With the launch of our innovative SaaS platform that improves risk adjustment initiatives for payers and risk-bearing providers, an ECLAT partnership provides organizations multiple options to improve current processes and drive better accuracy and correct results in your RAF HCC Coding.

If you're encountering any of these issues or if you aim to make process improvements, reduce costs or achieve clear visibility with reporting and data, click below to talk to our team about how ECLAT will drive these results.


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1https://bok.ahima.org/doc?oid=302516#.YenwQpNKit9 | AHIMA

2https://www.aapc.com/blog/69260-is-meat-satisfying-your-raf-hunger/ | AAPC

3https://www.beckershospitalreview.com/podcasts/podcasts-beckers-hospital-review/dr-robert-budman-cmio-at-nuance-79215608.html | Becker's Hospital Review

4https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-health-care-outlook-Final.pdf | Deloitte

Tags: Coding, HCC, HCC coding, HCC Coding Services, Risk Adjustment, RAF Score, HCC Risk Score