HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Different patients have different counts of variables that influence their health. Disability negatively interacts with some conditions. 1516 Folsom St Unit C The term risk adjustment factor highlights CMS’s use of risk scores to adjust its monthly capitation payments to MA plans. disabled status. the problem list in the patient’s medical record). That’s the hierarchical relationship between the two condition categories. Variables with less risk have lower coefficients (e.g. The new-enrollee model is less complex because it creates risk scores without all the normal data sent to CMS for continuous enrollees. AVERAGE MEDICARE PATIENT’s RAF IS 1.0 National Average 1.0 = $9000 non-MA CMS reimburses 1% HIGHER for every 0.01 RAF increase Approximately $900 for ever 0.1 RAF increase PATIENT RAF Score DIAGNOSIS CODING DRIVES THE RAF SCORE RAF SCORE DRIVES THE REIMBURSEMENT PROPER DOCUMENTATION RETAINS THE REIMBURSEMENT Adjustments to Risk Score That’s true whether the patient has one or multiple conditions in one category. There are two broad categories of these conversion factors—the demographics and the disease burden of the beneficiary. 7500 Security Boulevard, Baltimore, MD 21244 CMS & HHS Websites [CMS Global Footer] Medicare… CMS-HCC risk scores adjust Medicare payments to Medicare Advantage plans. 200 Independence Avenue SW . The RAF score is the sum of “conversion factors”—decimals that can adjust the county rate up or down. A beneficiary's RAF is based on health conditions the beneficiary may have (specifically, those that fall within a Hierarchical Condition Category, or HCC), as well as demographic factors such as Medicaid status (defined as having at least one month of … Note: the full list of category hierarchies is included in this guide under “disease hierarchies” in the appendix. As you can see, categories intersect with variables to create the different values of each coefficient. By the way, if you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. The terms risk score and risk adjustment factor (RAF) are synonymous terms that refer to the same number, meaning the output of the CMS-HCC model. However, the Balanced Budget Act of 1997 required Medicare to start to use risk scores to adjust capitation payments in January 2000. A RAF score, or risk adjustment factor score, is a medical risk adjustment model used by the Centers for Medicare & Medicaid Services (CMS) and insurance companies to represent a patient’s health status. Patients fall into one of seven categories which is why the example shows the sum of coefficients for only one category (Community, NonDual, Aged). In 2003, the Centers for Medicare and Medicaid Services (CMS) implemented Risk Adjustment Factors (RAF) and Hierarchical Condition Category (HCC) coding to identify individuals with serious and/or chronic illnesses and assign them a risk factor score that is based on a combination of demographic information and reported diagnoses. This guide explains the CMS-HCC model which is different than the HHS-HCC model. That’s because a risk score is an actuarial tool. HCC codes are not always intuitive. In the example below, notice that vascular disease progresses across different condition categories: HCC107 and HCC108. CMS requires an encounter each calendar year and diagnosis by an APRN, PA or physician. RAF is a numeric value assigned by CMS to identify the health status of a patient. became entitled to Medicare because of a disability. This means there is a flat fixed rate for every member, and the score increases depending on the individual RAF score. Some codes have RAF value. Some do not. Also, in most cases, but not all, males require more care and therefore more financial resources. highlights CMS’s use of risk scores to adjust its monthly capitation payments to MA plans. The Center for Medicare & Medicaid Services’ (CMS) Hierarchical Condition Category (HCC) risk adjustment model assigns a risk score, also called the Risk Adjustment Factor or RAF score, to each eligible beneficiary. The risk score for an average patient is 1.000. Medicare uses the HCC method to calculate the risk score. The quantified risk of each variable is the variable’s. The solution calculates risk scores using both your claims and clinical data. Demographic factors include age and sex. In addition, each patient receives a Demographic RAF score based on their age, sex and whether the patient is community-based or living in a skilled nursing facility (SNF). Patients disabled today may or may not have become entitled to Medicare because of a disability. RAF Scores. And even though the name of the model is the CMS-HCC model, variables include factors beyond HCCs. Chronic and some Acute Conditions . More details about the CMS-HCC structure can be found in Appendix C. Yearly Reporting Requirement Each chronic medical condition diagnosed impacts the RAF score of a patient. The CMS-HCC model quantifies risk differently for new enrollees versus continuous enrollees. Able Health identifies uncaptured HCCs in two ways: 1) diagnoses billed on claims in previous measurement periods and 2) diagnoses in a patient’s problem list that have never been billed (i.e. CMS. For example, the CMS-HCC model does not assign this status to patients that are now disabled but originally became entitled to Medicare because of age. – PY 2019 coding adjustment factor) X 75% = portion of the risk score from RAPS & FFS Portion of risk score based on ED, RAPS inpatient records & FFS data using the 2019 CMS-HCC model (i.e., updated CMS -HCC model without count variables): 25% [(raw risk score from ED + RAPS inpatient records + FFS diagnoses) / (PY 2019 normalization factor Date: April 12, 2018 . Community vs. Institutional Status . A patient would have one risk score that corresponds to the patient’s category (e.g. Age and sex influence a patient’s health status. In other words, plans cannot profit by enrolling only healthy patients and dropping unhealthy patients. Incorrect or non-specific diagnoses (or patient demographic information) can affect both patient outcomes and reimbursement for the care of that patient, moving forward. A score of 1.00 is average, with the decimal places representing percentages above or below average. Cherry picking is a term that refers to when a plan enrolls only healthy patients to ensure it spends less on those patients. Risk-scoring models create seven categories of patients: Live in an institution or in the community (community vs. institution), Are dual eligible for both Medicare and Medicaid or are not dual eligible (dual vs. non-dual), Are full-benefit (FB) or partial-benefit (PB) dual-eligible enrollees (FB vs. PB), Became eligible for Medicare through age or disability (aged vs. disabled), CMS-HCC – elderly and disabled in MA plans, HHS-HCC – children and adults in plans offered on ACA health exchanges, CMS-HCC – base Medicare’s capitation payments to MA plans on patient risk, HHS-HCC – redistribute money from plans with lower-risk patient populations to plans with higher-risk patient populations. A beneficiary’s RAF is based on health conditions the beneficiary may have (specifically, those that fall within a Hierarchical Condition Category, or HCC), as well as demographic factors such as Medicaid status (defined as having at least one month of Medicaid eligibility during the base year), gender, aged/disabled status, and whether a beneficiary lives in the community (i.e., beneficiaries who reside in the community or have been in an institution for fewer than 90 days) or in an institution (i.e., beneficiaries who have been in an institution for 90 days or longer). The seven categories are mutually exclusive, meaning CMS identifies patients in only one of the seven categories. Patient categories identify current disabled status, but they do not identify originally disabled status. Centers for Medicare & Medicaid Services . The source of the EDS RAF score … Key terms discussed in detail throughout the rest of this guide: By the way, if you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. That’s because each variable creates a different amount of incremental risk. The 2019 benefit year final HHS risk adjustment model factors included in the HHS Notice of You can find the new-enrollee model in the appendix for this guide under “CMS-HCC model for new enrollees.”. The CMS-HCC risk model quantifies the impact of those interactions for institutional patients. For example, older individuals typically have a higher RAF than younger individuals; and, those individuals with a personal or family history of certain conditions may garner a higher RAF than individuals without such a history. The interaction coefficient adds to the coefficients for the individual HCCs. However, the Balanced Budget Act of 1997 required Medicare to start to use risk scores to adjust capitation payments in January 2000. Actual Medicare payments: $11,400 (average cost) X 5,000 = $57,000,000, Actual plan costs: $5,700 (0.5 risk score) X 5,000 = $28,500,000, Financial advantage: $57,000,000 (payments) – $28,500,000 (cost) = $28,500,000 (margin). The coefficient for one HCC contributes only once to the risk score for each patient. The terms risk score and risk adjustment factor (RAF) are synonymous terms that refer to the same number, meaning the output of the CMS-HCC model. Below is the list of disabled/disease interactions. Documentation in the medical record must support the presence of the condition and indicate the provider’s assessment and plan for management of the condition. The CMS-HCC model groups similar conditions (diagnoses) into categories called hierarchical condition categories (HCCs). The Center for Medicare & Medicaid Services’ (CMS) Hierarchical Condition Category (HCC) risk adjustment model assigns a risk score, also called the Risk Adjustment Factor or RAF medical abbreviation “RAF score”, to each eligible Medicare Advantage (MA) beneficiary. Payment rates may vary based on a patient’s predicted level of risk (e.g., the expected cost to maintain that patient’s health). The new-enrollee model is less complex because it creates risk scores using demographic data rather than detailed diagnoses data. Use this calculator to see how various demographics and patient conditions affect a person's risk score. Subject: 2019 Benefit Year Final HHS Risk Adjustment Model Coefficients . RAF Score . That’s how the originally disabled status is unique and necessary. Total RAF score 2.223 PMPM payment $1,778 Annual payment $21,341 Roberta Smith’s clinical picture: Type 2 diabetic with CKD stage 5, chronic diastolic CHF, & COPD Demographics Diagnoses supported in encounter documentation Interaction coefficients added by CMS Risk score Risk adjustment payment Provider impact – Variables is a term that refers to specific factors that influence the health status of patients. CMS calculates a risk score, or “risk adjustment factor” (RAF) score, for each individual beneficiary and provides this information to each ACO quarterly. For example, the coefficients for diabetes with complication (HCC18) are the same for diabetes with acute complications (HCC17). Not so much complicating, but certainly not simplifying submissions, CMS confirmed RAF scores for PY 2020 will be calculated from RAPS data, leveraging the 2017 HCC model. That’s why age and sex are both variables. MA plans could gain a financial advantage through cherry picking and lemon dropping if Medicare did not risk-adjust capitation payments to plans. Risk Score Calculator. Then, Medicare uses risk scores to adjust Medicare payments to MA plans. Center for Consumer Information and Insurance Oversight . The model quantifies the impact by establishing unique variables for specific interactions. Those risk-adjusted payments discourage plans from cherry picking and lemon dropping patients, ensuring access to healthcare for all Medicare beneficiaries regardless of their health status. Health conditions influence a patient’s health status. The RAF score identifies the members health status and drives reimbursement. The average CMS FFS patient has the score of 1.00 •RAF is a numeric value assigned by CMS to identify the health status of a patient •RAF scores are made up of the following criteria for each member: Demographic information e.g. 7/6/17 5 • CMS = Centers for Medicare and Medicaid Services • HCC = Hierarchical Condition Category • A prospective risk adjustment model that uses retrospective demographic data and medical diagnoses to calculate a risk score that predicts future health expenditures • The … Able Health is a Qualified Registry for data submission under the Merit-Based Incentive Payment System (MIPS). For example, each MRI performed, or unit of anesthesia would be billed at a predetermined rate. Patient RAF Score . That’s because a risk score is an actuarial tool. Documentation must be accurate and support the diagnosis. Medicare based payments completely on risk scores starting in 2007. An individual may have zero, one, or multiple HCCs that impact the RAF score that is calculated each calendar year. RAF(PatientAcuityScore) • If Claims Paid are the same for 2 populations, using a Risk Score calculates an effective cost for each group of patients • A Lower Acuity Score results in a higher cost for patient care. As an extreme example, over 300 diagnoses map to HCC59 (major depressive, bipolar, and paranoid disorders). Training & Presentations; Coding FAQs; Tools; HCC Blog; Terms of Use; Legal Disclaimers; Copyright © 2004-2021 SCAN Health Plan. If you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. Variables include: Here’s an example that incorporates all of those variables. s is a term that refers to specific factors that influence the health status of patients. Medicare Advantage and exchange plans are paid based on patients' RAF scores. And the same variable has different coefficients for different patient categories. And that’s why conditions, primarily chronic conditions, are variables in a patient’s risk score. The count of HCC’s for a given patient influences a patient’s health status. The CMS-HCC risk model quantifies the risk of the count of HCCs for a given patient. Hierarchical categories represent disease hierarchies, meaning progression and severity. Click here. If Medicare’s baseline capitation payment (aka benchmark rate) is $950 per month, Medicare would pay a MA plan the following annual totals for each corresponding RAF (note: benchmark rates are specific to each county): As you can see, the word risk in the terms risk score and risk adjustment factor ultimately refers to financial risk. It also tracks captured and uncaptured HCCs to automate chart prep and identify patients to recall. The model only includes factors known to predictably influence a patient’s cost of care. Disability appears in the CMS-HCC model in 1) patient categories and 2) the originally disabled status. High Medicare spending per beneficiary in … A score of 1.00 is average, with the decimal places representing percentages above or below average. HCC reporting for an 82-year-old female: Scenario 1: RAF base score 0.7 – Based on demographics for an 82-year-old female - age, sex, community vs. SNF, Medicare/Medicaid eligibility CMS uses risk scores created by the CMS-HCC model to adjust Medicare capitation payments to Medicare Advantage (MA) plans. Some condition categories are hierarchical, but not all. The CMS-HCC risk model identifies patients that. Able Health identifies uncaptured HCCs in two ways: 1) diagnoses billed on claims in previous measurement periods and 2) diagnoses in a patient’s problem list that have never been billed (i.e. An RAF score is a metric tied to each individual member, which reflects the health status of that member used by CMS to calculate payment. San Francisco, CA 94103, are synonymous terms that refer to the same number, meaning the output of the CMS-HCC model. Sign up to receive alerts about key MIPS and MACRA information and dates. Categories is a term that ultimately refers to categories of patients. The largest change in community risk scores was a decrease of -0.04 in the full-dual disabled mean risk score. Able Health accepts data as a clinical registry and uses the data to improve population health outcomes. Below is an example of HCC85, HCC96, and the HCC85_HCC96 interaction variable. To learn more, schedule a meeting with an Able Health expert. The CMS-HCC risk model identifies low-income patients by a patient’s enrollment in Medicaid. Despite the differences, people using those three terms are referring to the same thing. The solution calculates risk scores using both your claims and clinical data. It also tracks captured and uncaptured HCCs to automate chart prep and identify patients to recall. The table below demonstrates the difference: Some HCCs negatively interact with other HCCs (aka comorbidities). Notice how age and sex affect the coefficients in the sample table below (note: the example highlights only the ages of 65-79 for brevity): You probably noticed that three of the categories are blank in the example above. • $10,000 ÷0.92 = $10,970 Risk Adj Cost • A Higher Acuity Score means sicker patients are being cared for with lower costs. With risk-adjusted payments, Medicare pays MA plans more money for patients with greater risk and less money for patients with less risk. The Center for Medicare & Medicaid Services’ (CMS) Hierarchical Condition Category (HCC) risk adjustment model assigns a risk score, also called the Risk Adjustment Factor or RAF score, to each eligible beneficiary. Patient categories identify, disabled status, but they do not identify. Lemon dropping is a term that refers to when a plan drops unhealthy patients to stop spending more on those patients. This appendix includes the full list of disease hierarchies and the complete CMS-HCC model for new enrollees. Care for patients with a risk score of 2.000 is expected to cost 2X the amount of average financial resources. Hierarchical Condition Categories (HCC) List Source Description RAF Source Description RAF Source Description RAF HCC 1 HIV/AIDS 0.470 HCC 55 Drug/Alcohol Dependence 0.420 HCC 106 Atherosclerosis of the Extremities with Ulceration or Gangrene 1.413 HCC 2 Septicemia, Sepsis, Systemic Inflammatory Response The numbers are based on … Some patients have few variables while others have many. Without exact income information for each patient, a Medicaid status is CMS’s best indicator of patient income. The model quantifies the risk by establishing unique variables for different HCC counts. On average, older patients require more care and therefore more financial resources. Different patients have different variables that ultimately impact each patient’s risk. Note, however, that not all HCC coefficients increase within a disease hierarchy. Able Health identifies uncaptured HCCs in two ways: 1) diagnoses billed on claims in previous measurement periods and 2) diagnoses in a patient’s problem list that have never been billed (i.e. Prepare for certification and a career with Risk Adjustment training, Validate your knowledge, skills, and expertise with Risk Adjustment certification, © Copyright 2021, AAPC Attribution RAF scores of less than 1. The CMS-HCC risk model identifies patients that originally became entitled to Medicare because of a disability. Medicare’s risk-adjusted capitation payments discourage MA plans from cherry picking and lemon dropping. Notice in the image below how the solution identifies an uncaptured HCC that is the HCC at the top of the diabetes hierarchy: Some condition categories are hierarchical, but not all. age and sex Medicaid status and Medicare eligibility due to a disability Chronic conditions and disease interactions 10 For example, the CMS-HCC model does not assign this status to patients that are now disabled but originally became entitled to Medicare because of. The term risk adjustment factor highlights CMS’s use of risk scores to adjust its monthly capitation payments to MA plans.