Automated RAF Scoring to Optimize Medicare Advantage Reimbursements

Accurate reimbursement requires accurate documentation and coding of risk

Medicare Advantage and other risk-bearing reimbursement programs rely on proper documentation of Hierarchical Condition Category (HCC) coding and Risk Adjustment Factor (RAF) scores to estimate patient care expenses and calculate provider reimbursement. To ensure accurate payments, providers participating in these programs must fully and accurately capture a patient’s condition on an annual basis, including complete and specific documentation for all of a patient’s qualifying diagnoses. Until now, providers have mostly relied on retrospective, manual chart reviews to identify possible documentation and coding gaps.

Risk Adjustment scores drive costs and reimbursements

Value-based payment programs typically rely on RAF scores to estimate patient care expenses and calculate provider reimbursement. RAF scores are calculated using hierarchical condition codes (HCCs), clinical documentation and other criteria. Traditionally, organizations have lacked automation tools to accurately determine HCCs and calculate RAF scores.

Quippe HCC Risk Optimizer identifies appropriate documentation  

Quippe HCC Risk Optimizer helps organizations identify proper coding for Medicare Advantage and other value-based reimbursement programs while increasing physician efficiency. Quippe HCC Risk Optimizer:

  • Verifies documentation in real time to discover HCC-eligible codes and potential gaps
  • Prompts physicians to verify if particular conditions are an HCC or could qualify as an HCC with more complete documentation and coding
  • Allows physicians to immediately address any treatment or coding gaps while patients are still in the exam room

Documentation during the visit, instead of retrospectively

Quippe HCC Risk Optimizer eliminates error-prone manual processes and ensures complete and accurate documentation so that physicians deliver the highest quality of care during the patient encounter.

Contact Medicomp

Medicomp’s RAF solution is powered by the Quippe Clinical Data Engine and Quippe documentation solutions. To learn more about how your organization can streamline the RAF scoring process and ensure accurate Medicare Advantage reimbursement, contact us.