South Bend Clinic Improves RAF Score Accuracy & HCC Coder Efficiency 

The Challenge

The South Bend Clinic (SBC) made a commitment to aggressively move into value-based care to improve patient care while reducing costs. However, in order to take on more risk-based contracts, a scalable and cost-effective approach to ensure profitability was a necessity.

SBC knew the key to their financial success in value-based contracts was accurate RAF scores.
They had already made major investments in a population health management solution and
worked to build an analytics infrastructure for case managers, care coordinators, and providers
with the goal to provide comprehensive preventative care, fill gaps in patient’s care, and
manage chronic disease. 

While SBC made great strides on clinical initiatives they realized there was a missing piece–their RAF scores did not accurately match up to their patient population. Their patients were sicker than their RAF scores indicated.

The goal: Cost-effectively Increase RAF scores.

"In a single week we saw an additional $100K+ in otherwise missing RAF value by using the RCxRules HCC Coding Software. With RCxRules, we were easily able to scale up with value-based contracts. The value of RCxRules software is unprecedented, in fact, it’s a necessity for any organization with risk-based contracts."
Kelly Macken-Marble
Kelly Macken-Marble CEO, The South Bend Clinic

The Solution

SBC hired a single HCC coder to concurrently review value-based encounters. They leveraged their coder and the RCxRules software to improve RAF scores through increased HCC capture/re-capture rates. The RCxRules software automated the review of 100% of SBC’s HCC encounters pre-claim to ensure the most accurate HCC data was captured and submitted. By flagging HCC coding gaps, the coder focused solely on high-value encounters needing extra attention.

The RCxRules Software

  • Automatically reviews every encounter that is finalized in the EMR
  • Identifies encounters with HCC coding gaps and tasks them to coders
  • Enables a concurrent/real-time review of encounters opposed to costly retrospective reviews
  • Provides reporting which shows provider recapture reports, as well as added/deleted HCCs
    and their effect on RAF value

The Results

By implementing RCxRules software, The South Bend Clinic achieved:

  • Increased average RAF score by 34% where supported documentation was uncovered.
  • Captured an additional $504,220 in RAF value in less than 2 months.
  • Potential to earn significant shared savings from their Medicare Shared Savings Program.
  • Realized software investment payback within the first month.

About South Bend Clinic

The South Bend Clinic, located in South Bend, Indiana, has nearly 150 providers, comprised of almost 30 different board certifications. Founded in 1916, the patient-centered organization has been serving their community for over 100 years.

 

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