HCC and RAF Management: The Key to Success in Value-Based Contracts

Hierarchical Condition Categories (HCC), a risk adjustment model that has been around for years, has attained heightened visibility since Medicare Advantage Plans began to require Risk Adjustment Factor (RAF) scores for reimbursement. Understanding how to manage your organizations RAF scores accurately can be your key to success for performance in value-based contracts.The RAF score is an objective measurement of the complexity of your patients and is used to risk-adjust quality and cost metrics in many value-based payment plans, e.g., Medicare Advantage and MIPS. Often, physicians say, “My patients are sicker and more complicated than most,” and the RAF score is the measurement by which the validity of this claim is determined. The Centers for Medicare and Medicaid Services (CMS) uses RAF scores to measure the needs of a patient or patient population and adjusts payments to providers based on their patient’s clinical complexity as determined by the RAF score.The provider can also use the RAF score to identify the most significant opportunities in his or her patient population to

  • Reduce the cost of care
  • Improve the quality of care
  • Optimize interdisciplinary care and care coordination

RAF data can be used to prioritize and focus efforts at the

  • Point of care
  • Within the practice
  • Across the organization

Suggested goals for RAF Management include

  • Achieve optimal risk adjustment factor (RAF) scores for the population, i.e., RAF scores that most accurately reflect the complexity and severity of illness of your patients
  • Compress the time to achieving optimal RAF each year by designing efficient and effective workflows around HCC and RAF score capture and reporting
  • Improve the productivity, efficiency, and effectiveness of resources used within the RAF management process

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