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The Impact of Accurate RAF Score Calculations

Posted By ECLAT Health Solutions

Calculating the correct Risk Adjustment Factor Score (RAF Score) the first time is both a vital indicator of process resiliency and an essential metric for compliance assurance, reimbursement accuracy and patient health in all risk-adjusted lines of business.

These endeavors are often assisted by SaaS technology which needs to create the clarity and transparency to make truly data-driven decisions with the time sensitivity required. Once determined, the variables of a patient’s health outcomes detailing expected and actual performance as well as the national average results can be plugged into the Centers for Medicare and Medicaid Services’ (CMS) formula below to calculate the correct Risk Adjusted Measure Score.



The numbers assigned to the patient’s profile are derived from the attributed HCC conditions for the calendar year. The patient’s HCC Coding profile is cleared by the government at the turn of each new year, causing these metrics to be recoded and calculated from a blank starting point every twelve months.2 The risk-adjusted conditions used to capture and encode this information also overlap with demographics that include some details comprised of Social Determinants of Health (SDoH) information, a driving force behind your ability to pursue a value-based care model.

The Risk Adjustment Factor score accuracy is every stakeholder’s urgent priority for three primary reasons: it strongly impacts your legal compliance standing with CMS, it allows you to receive the correct reimbursement for treatments provided for risk-adjusted patients and it ensures the patient is being treated based upon their real risk and health history.



Staying in Good Standing: Risk Adjustment Compliance

As correct Risk Adjustment Factor scores determine the reimbursements that your organization will receive from the federal government, it’s no wonder why accuracy, auditing and enforcement are chief concerns between CMS and the providers whom they oversee. RAF Score accuracy is vital for every commercial payer and risk-bearing provider.

In order to stay in good legal standing with CMS, best practices and ongoing internal facing and external vendor retrospective accuracy audits are a necessity.

Correct Reimbursement through Risk Adjustment Accuracy

While maintaining good standing with CMS is a motivating external factor to maintaining Risk Adjustment accuracy, there are internal factors as well. For organizational stakeholders, one of the chief concerns is to ensure accurate reimbursement for the treatments rendered based upon the patient’s individual risk. For example, documenting a patient with a lower risk score than medically necessary will result in a smaller reimbursement than you are actually owed from CMS.

To extrapolate how this might affect your own reimbursements at scale, let’s look at the data. As discussed in our recent blog on RAF Score health, an average RAF Score is 1.0 with higher scores representing sicker / riskier patients and lower scores indicating the opposite.3

The national average of CMS reimbursement is approximately 10% higher for each 0.1 increase to the Risk Adjustment Factor score.4 Since the national average reimbursement for a non-MA patient is $9,000,4 this means that each tenth of a point that a patient’s score increases or decreases can result in approximately $900 shifts per patient each and every tenth of a point inaccurately attributed. Inaccurate scores therefore can cause significant over or under-reimbursements by CMS, and both situations create an array of issues that your team must unravel. Therefore, quality risk adjustment coding and frequent internal auditing and reporting is vital to payers’ and risk-bearing providers’ financial health.

Ongoing Health: Leveraging RAF Score Audits to Better Patient Health

There are concerns about inaccurate RAF Scores that stretch beyond compliance and reimbursement. If a patient’s score is inaccurate, this is likely because the patient’s medical issues and risk are not fully documented in the patient record. This can have a wide-ranging impact on the patient’s health outcomes and make specific areas of medical concern more difficult to track if the patient visits a different provider for treatment (or if their case moves between specialists at the same provider).

Provider treatment performance and patient health will necessarily increase when risk-adjusted codes are accurately coded to enable risk adjustment scores to be correctly calculated and reported.

Achieve RAF Score Accuracy Consistently with ECLAT Health Solutions

Risk Adjustment accuracy is a crucial metric for all stakeholders in our nation’s medical services whether they are government agencies, payers, providers or patients. The best way to achieve these goals consistently is to partner with the expert Risk Adjustment team at ECLAT Health Solutions and to enhance your accuracy with our AI-Assisted Risk Adjustment SaaS Platform.

Click here to explore ECLAT’s technologically enabled approach and schedule your demo to see the advantages for yourself!


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  1. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2016-RiskAdj-FactSheet.pdf | CMS
  2. https://azhima.org/annualmeeting/wp-content/uploads/2016/08/RAF101_Updated.pdf | Banner Medical Group - Banner University Medical Group
  3. https://bok.ahima.org/doc?oid=302516#.YenwQpNKit9 | AHIMA
  4. https://www.tmgipa.com/rafcoding318a.pdf | TMGIPA

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