The RAF score is one factor used in determining risk. However, some experts suggest that two years of medical claims should be used instead of one. Others suggest using pharmacy use as a risk adjustment factor. Using the correct risk adjustment factor is crucial to determining if you’re at risk for poor health.
Obtaining an accurate risk adjustment factor (RAF) score for your HCCs is crucial for obtaining government reimbursement. To calculate your RAF score accurately, it is essential to document all clinical data correctly. Physicians can improve the accuracy of their RAF score by implementing the right software tools that support the documentation process. These software tools can help reduce the time and effort required to document the risks associated with HCCs.
Using hierarchical condition category coding, you can communicate the complexity of each patient and provide a holistic picture of their health. This information can help you accurately predict cost and healthcare resource utilization. It can also help you risk-adjust your cost and quality metrics.
The CMS-HCC crosswalk is a tool used to assign risk adjustment factors to HCCs. It is based on the 2018 master list of CMS-HCC categories and the associated ICD-10 codes. To help understand how these risk adjustment factors work, review Table 1. The table shows the most commonly-diagnosed ICD-10 codes and their respective CMS-HCC categories. In addition, it describes the weights associated with these codes for different demographic groups.
CMS-HCC crosswalks are relatively simple to use. Medical coders working with the HCC coding model may access the information on the crosswalk in different ways. For example, some coders use an HCC spreadsheet to find a specific ICD-10-CM code. However, many coding software providers provide an HCC add-on, which allows the HCC crosswalk to list all HCC-relevant conditions.
Social Determinants of Health
Social determinants of health are conditions that contribute to the health of individuals and communities. These factors include socioeconomic status, education, physical environment, employment, and social support. These factors increase the risk of many diseases, shorten life expectancy, and influence health behaviors. Social determinants influence more than 80 percent of health-related outcomes.
While social factors are a natural risk adjustment factor, they can exacerbate inequalities in access to care. For example, high-risk communities may receive higher payments for health-related services than low-risk communities, while low-risk individuals may receive less. In addition, adjusting payments for social needs can create trade-offs: higher payments for those with high ADI may mean lower payments for those with low income or multiple chronic conditions. However, risk adjustment can be made more equitable by incorporating complementary policies that target specific populations with high social needs.
The CMS-HCC 19 risk adjustment factor is a prospective measure of the risk of contracting HCC. This model uses diagnosis codes and base year demographic information to calculate each patient’s risk score. The risk score is then multiplied by a base rate reflecting that population’s risk. CMS uses this method to calculate capitated payments to Medicare Advantage plans and for care provided in some demonstration projects.
The risk adjustment factor, or RAF, is a numerical value that reflects a patient’s estimated cost of care based on their disease burden and other relevant demographic data. This value is multiplied by a predetermined amount, known as the per-member-per-month or capitated reimbursement. It is not based on the services the patient receives.
Priority Health’s Internal Risk Adjustment Program
Health plans, use internal risk adjustment programs to monitor the health of their members and lower the cost of their care. These programs rely on the accuracy and completeness of data submissions to calculate risk scores, which are used to lower the cost of care for plan members. The program’s formula uses age, gender, and chronic and status conditions to determine a member’s risk score.
An entity administering the risk adjustment program must collect data from insurers to establish a risk-based system. Then, based on that data, the entity must determine the average risk scores of its plans. Once this information is gathered, the risk-adjustment entity will calculate distributions and adjust premiums.