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. • HCC RAF scores are tabulated yearly o The physician must examine the patient each year and compliantly document the status of all chronic ... *Nine Medicare Advantage Plans Receive Five-Star Ratings in 2012, CMS Data Show Wednesday, October 19, 2011 Humana Wisconsin Health. Disability appears in the CMS-HCC model in 1) patient categories and 2) the originally disabled status. The CMS-HCC risk model quantifies the risk of the count of HCCs for a given patient. Download our Excel spreadsheet of MIPS 2021 quality measures to assist in measure selection for MIPS and for easy reference to measure descriptions and details. The term risk adjustment factor highlights CMS’s use of risk scores to adjust its monthly capitation payments to MA plans. That’s true whether the patient has one or multiple conditions in one category. As you can see, Coefficients – the quantified risk of each variable, Variables – specific factors that influence the health status of patients, Categories – a unique combination of special factors, meaning factors not included in the list of variables, To calculate risk scores for different patients, the CMS-HCC model first quantifies the risk of different variables. Overall, risk scores in the new version increased only slightly by 0.78% in our study, which is less than the 1.1% projected by CMS. If you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. Sign up to receive alerts about key MIPS and MACRA information and dates. The new-enrollee model is less complex because it creates risk scores using demographic data rather than detailed diagnoses data. That’s the hierarchical relationship between the two condition categories. As an extreme example, over 300 diagnoses map to HCC59 (major depressive, bipolar, and paranoid disorders). 1516 Folsom St Unit C Medicare uses risk scores to quantify the expected healthcare costs for each Medicare beneficiary. Subject: 2019 Benefit Year Final HHS Risk Adjustment Model Coefficients . And the CMS-HCC risk model quantifies the risk of this status as a unique variable. Prepare for certification and a career with Risk Adjustment training, Validate your knowledge, skills, and expertise with Risk Adjustment certification, © Copyright 2021, AAPC 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 CMS-HCC model groups similar conditions (diagnoses) into categories called hierarchical condition categories (HCCs). 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. 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 – Cherry picking is a term that refers to when a plan enrolls only healthy patients to ensure it spends less on those patients. The term. Medicare uses the HCC method to calculate the risk score. Be the first to know about key MACRA and MIPS information, deadlines, and expert analysis. Different patients have different counts of variables that influence their health. 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. 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. Medicare’s risk-adjusted capitation payments discourage MA plans from cherry picking and lemon dropping. 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. And the CMS-HCC risk model quantifies the risk of this status as a unique variable. 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 … The largest change in community risk scores was a decrease of -0.04 in the full-dual disabled mean risk score. The coefficient for HCC107 includes the coefficient for HCC108 but adds risk due to the progression in the disease hierarchy. Risk scores quantify and compare the expected healthcare costs for a specific patient relative to the expected healthcare costs for an average patient. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). For example, if a plan's average patient RAF score is 1.10, it will receive 10 percent more from Medicare. By the way, if you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. In other words, for the same variable, the coefficient is different in the seven different patient categories. 2.659 for metastatic cancer and acute leukemia). A score of 1.00 is average, with the decimal places representing percentages above or below average. On average, older patients require more care and therefore more financial resources. Able Health is a Qualified Registry for data submission under the Merit-Based Incentive Payment System (MIPS). 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. A patient would have one risk score that corresponds to the patient’s category (e.g. The table below demonstrates the difference: Some HCCs negatively interact with other HCCs (aka comorbidities). Notice the different coefficient values in the example below (highlighting only two HCCs for brevity): Coefficients range from 0.002 to 5.906 across all variables and categories. That’s because those categories do not apply to patients 65 and older. Note: the full list of category hierarchies is included in this guide under “disease hierarchies” in the appendix. In other words, plans cannot profit by enrolling only healthy patients and dropping unhealthy patients. It also tracks captured and uncaptured HCCs to automate chart prep and identify patients to recall. Use this calculator to see how various demographics and patient conditions affect a person's risk score. 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. the problem list in the patient’s medical record). (The average Medicare patient has a RAF score of 1.) The seven categories are mutually exclusive, meaning CMS identifies patients in only one of the seven categories. Increased severity doesn’t usually increase risk adjustment factor (RAF). Meanwhile, EDS data will leverage the new APCC model, at a 50/50 split. 200 Independence Avenue SW . 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. CMS. 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 RAF is a numeric value assigned by CMS to identify the health status of a patient. The RAF is used to adjust capitated payments for beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration projects. Below is an example of HCC85, HCC96, and the HCC85_HCC96 interaction variable. Note, however, that not all HCC coefficients increase within a disease hierarchy. By the way, if you need a better way to calculate and track risk scores, consider using the Able Health risk scoring solution. You can find the new-enrollee model in the appendix for this guide under “CMS-HCC model for new enrollees.”. 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. Interactive Medicare HCC RAF Calculator. The model quantifies the impact by establishing unique variables for specific interactions. Notice in the image below how the solution identifies the breakdown of risk scores for each patient: To calculate risk scores for different patients, the CMS-HCC model first quantifies the risk of different variables. Risk-scoring models create seven categories of patients: Notice that the seven categories represent different combinations of these four alternatives, meaning whether patients: As shown in previous examples, the CMS-HCC model quantifies different risk for the same variable for patients in different categories. HCC codes are not always intuitive. the problem list in the patient’s medical record). The solution calculates risk scores using both your claims and clinical data. Hierarchical categories represent disease hierarchies, meaning progression and severity. Some patients have few variables while others have many. Adjustment Factor (RAF) score based on complexity of the disease; this functions similarly to the weighting of the diagnosis-related groups (DRGs) for acute inpatient payments. Date: April 12, 2018 . 7500 Security Boulevard, Baltimore, MD 21244 CMS & HHS Websites [CMS Global Footer] Medicare… Washington, DC 20201 . The interaction coefficient adds to the coefficients for the individual HCCs. 27 The RAF is a relative measure of the probable costs to meet the healthcare needs of the individual beneficiary. That’s how the originally disabled status is unique and necessary. It also tracks captured and uncaptured HCCs to automate chart prep and identify patients to recall. That’s because a risk score is an actuarial tool. Here’s how that works. Privacy Policy | Terms & Conditions | Contact Us, Certified Documentation Expert – Outpatient, Certified Professional Compliance Officer, Risk Adjustment Paints a Valuable Picture, Understanding the HHS-HCC Risk Adjustment Model, 4 Key Areas to Risk Adjustment Documentation, Top 10 Medicare Risk Adjustment Coding Errors, Medicare Risk Adjustment: Financial Incentives May Lead to Bad Practices. The CMS-HCC risk model quantifies the impact of those interactions. These relative factors contribute to the patient’s RAF. Patients may have multiple conditions in one HCC because many conditions map to one HCC. The seven categories are mutually exclusive, meaning CMS identifies patients in only one of the seven categories. RAF Score . Medicare based payments completely on risk scores starting in 2007. Inpatient Hospitals: Penalties in the Hospital Readmission Reduction Program and/or mortality outcome measures. 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. With risk-adjusted payments, Medicare pays MA plans more money for patients with greater risk and less money for patients with less risk. While HHS based its model on the CMS model, the two differ to address distinct populations and purposes: Need a PDF copy of this guide? The table below demonstrates the difference: is a term that ultimately refers to categories of patients. Without exact income information for each patient, a Medicaid status is CMS’s best indicator of patient income. Variables with less risk have lower coefficients (e.g. Three synonymous terms refer to the same output from the CMS-HCC model: risk score, risk adjustment factor (RAF score), Medicare risk adjustment (MRA). Attribution RAF scores of less than 1. Different patients have different variables that ultimately impact each patient’s risk. 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. Notice in the example below that a patient’s risk score is simply the sum of the coefficients for each patient variable (0.323 + 0.250 + 0.331 = 0.904): Patients fall into one of seven categories which is why the example shows the sum of coefficients for only one category (Community, NonDual, Aged). Demographics. Every 1-2 years, CMS releases a table of conversion factors for patient demographics through it’s website. In the example below, notice that vascular disease progresses across different condition categories: HCC107 and HCC108. Risk Score Calculator. Patient RAF Score . Some condition categories are hierarchical, but not all. CMS-HCC risk scores adjust Medicare payments to Medicare Advantage plans. highlights CMS’s use of risk scores to adjust its monthly capitation payments to MA plans. However, the Balanced Budget Act of 1997 required Medicare to start to use risk scores to adjust capitation payments in January 2000. This means there is a flat fixed rate for every member, and the score increases depending on the individual RAF score.
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