Automated RAF Scoring to Optimize Medicare Advantage Reimbursements

The Problem

Medicare Advantage and other risk-bearing value-based payment programs rely on Risk Adjustment Factor (RAF) scores to estimate patient care expenses and calculate provider reimbursement. RAF scores are calculated using several criteria, including hierarchical condition codes (HCCs) and clinical documentation.

Higher RAF scores drive higher reimbursement.

The accurate calculation of risk and prospective costs of care requires physicians to fully and correctly capture a patient’s condition, including complete and specific documentation for all of a patient’s qualifying diagnoses on an annual basis.

Until now, providers have mostly relied on retrospective, manual chart reviews to calculate a patient’s RAF score and identify possible gaps in documentation and coding. Such processes are time-consuming, prone to error, and may require patients to return for follow-up care so that physicians can update documentation to ensure compliance.

Most organizations lack automation tools to verify that clinicians are accurately and fully documenting all the information required for accurate RAF scoring – which means providers could be leaving money on the table.   Current solutions also lack the ability to educate providers regarding proper documentation.

The Solution

Medicomp Systems’ ground-breaking automated RAF  solution helps organizations optimize Medicare Advantage reimbursement, while increasing physician efficiency. The solution verifies documentation in real-time and identifies potential revenue-impacting gaps.

As a physician documents a patient an encounter at the point of care, the system automatically reviews the patient’s chart to discover HCC-eligible codes.

When potential HCC codes are identified, the physician is prompted at the point of care to verify whether a particular condition is an HCC, or could qualify as an HCC with more complete documentation and coding.

The physician can then use Quippe’s Clinical Data Engine to immediately address any treatment or documentation gaps that could prevent maximum reimbursement.


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.