The RCxRules Blog

Why Are My RAF Scores Low?


What is a RAF Score?

A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient’s health status. RAF scores are used to predict the cost for a healthcare organization to care for a patient. A patient’s RAF score is based on health conditions that map to a Hierarchical Condition Category, or HCC, as well as demographic factors. Accurate RAF scores are critical to healthcare organizations since they ensure there is funding to provide high quality patient care.     

Achieving accurate RAF scores is no easy feat. You may be asking the question, “why are my RAF scores low?” or “why don’t my RAF scores reflect my patient population?” and if so, you’re not alone.

Here are three common reasons your RAF scores may be inaccurate:

1. You’re Not Using HCC Coders

Completely documenting and capturing HCC codes for each patient is critical to achieving accurate patient risk scores and ensuring appropriate reimbursement. It’s estimated that the average organization could increase reimbursement rates by 20% through the use of coding reviews1.

Many medical organizations rely heavily on physicians when it comes to capturing accurate HCC codes. Physicians are already busy doing what they do best: working diligently to treat patients while fully documenting their conditions in their clinical notes. Given a doctor’s limited time to capture codes and the intricacies involved, they are often not best equipped to choose the most accurate and complete set of diagnosis codes appropriate for their patient.

That's where coders come in. Coders specialize in turning the wealth of information found in a physician's documentation into the correct coding, which makes them an essential resource for organizations operating under value-based contracts.

According to a workshop offered through RISE Healthcare, vendors estimate that 80% of chronic conditions noted in the patient’s chart are not coded on the claim.2 That’s just not good enough. If you don’t have HCC coders on staff—or don’t have enough of them—it’s time to consider hiring some.

Get Your Top 10 HCC Codes Now

2. You’re Only Performing Retrospective HCC Coding Reviews

While a retrospective HCC coding review, which occurs after the initial claim has been submitted to a payer, is better than no coding review at all, it’s a highly manual, costly, and cumbersome process that places an intense administrative burden on healthcare organizations.

Implementing prospective and concurrent review processes can not only help eliminate the need for retrospective reviews—it can also increase productivity and RAF score accuracy for the first claim submission.

A prospective review process can be as simple as focusing on the pre-visit planning process for patients. For example, identifying patients with chronic conditions before their visit and updating those conditions in your EMR’s problem list.

For concurrent reviews, many organizations leverage their existing revenue cycle management processes, and make a few critical refinements to optimize for HCC coding. The result is a workflow that ensures the capture of all properly documented HCC codes before claim submission, much as their peers in traditional fee-for-service have done with billing issues for years.

3. Your Stakeholders Aren’t Communicating

Value-based care is a team sport. To excel, providers, care coordinators, coders, and financial staff all need to work together.

As we’ve just noted, accurate patient RAF scores are driven by correct documentation by clinicians and by coding specialists ensuring accurate HCC capture. If your providers are not clearly and completely documenting a patient’s chronic condition, your coders won’t be able to include appropriate and specific diagnosis codes on the claim. There must be a communication protocol or process in place to ensure that your doctors and coders are working together.

To improve communication and results, many leading organizations employ care coordinators to prepare providers for their day’s patients, especially those with chronic conditions. This assistance ensures that providers know ahead of time which of their patients require extra time and attention, and in most cases improves their documentation.

In the value-based world, studies have shown that the ICD-10 coding of patient encounters can have error rates around 20-50% even before data entry and management errors are considered.3 To mitigate the risk of inaccuracies, practices like these can help ensure more accurate HCC coding, RAF scores, and reimbursement rates.

In the fee-for-service world we would never send out a claim without a biller/coder review, so why wouldn’t we implement a similar process with our value-based business? By making HCC coding specialists a key part of your team, performing prospective and concurrent reviews, and ensuring that all of your stakeholders are working in concert, you can help make accurate RAF scores—and appropriate compensation—a reality for your organization.

Learn how our HCC coding software can improve HCC coding accuracy and risk adjustment performance today! Set up a 15-minute meeting to learn more.

The HCC Coding- Improve RAF Score Accuracy and Boost Staff Efficiency. Learn More.


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