Why RAF Compliance Optimization is important

• More than 50% of Medicare beneficiaries are now enrolled in MA plans.
• Since 2021, chronic conditions among Medicare beneficiaries have skyrocketed.
• Due to this rise in chronic conditions, beneficiaries are trapped in their MA plans. Going back to regular Medicare is not possible because they would not be able to afford their high-risk Medicare Part G Supplement insurance premiums. Without TINs taking action, this will be inevitable and cause a huge spike in lost reimbursement and write-offs.
• Providers need the best-in-class technology and support to ensure timely reimbursement and an increase in claims acceptance by MA plans.
• TINs need help negotiating better capitated agreements terms with MA plans.

CMS Final Rules

CMS’s Risk Adjustment Data Validation (RADV) and Transaction Coding of Diagnoses Final Rules, and the National Quality Strategy (NQS) are in effect. These have and will continue to create lower reimbursement and a significantly higher risk of an audit.  In addition, The Transactional Coding of Diagnoses to support billing in a fee-for-service environment is NOT adequate to meet VBC program care requirements.

Though most TINs did a good job with meeting compliance in the past, due to complexity and the failure of vendors and health plans to provide TINs and their providers with the proper expertise, tools, and/or training, most are NOT meeting RAF compliance benchmarks and targets.

Administrators even boast about their cost of care, robust risk adjustment, abstract coding teams, QA audit teams, and provider education. Unfortunately, too many are still apathetic about verification and action needed, because up until now, fully meeting requirements has not amounted to any significant increase in revenue. This has now changed.

So, now when ownership, boards, and/or stakeholders ask why your TIN’s MA reimbursement has been reduced or why you failed to maximize it and no one can explain why or do anything about it, ignorance or apathy will not be an accepted excuse. Don’t let this happen to you!

The high cost of doing business has been met with inadequate increases in reimbursement by CMS and increasing administrative burden due to inappropriate commercial health insurer practices.

RAF and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997 and originally created to estimate future healthcare costs for a patient

It was implemented in 2004 and designed to identify patients with serious or chronic illness and assign a risk factor score to the patient based upon a combination of their health condition and demographic details. And as healthcare shifts towards more value-based payment models; HCC coding has become more prevalent.

RAF scores use a patient’s demographics and diagnoses to determine that patient’s risk score. This score measures how costly a patient is predicted to be for the current year. Within this payment model, patients in the same practice could have a different payment rate. The risk assessment data used is based off claims and medical records collected from doctors’, in-patient hospital visits, and outpatient clinics from the previous year.  A multitude of factors determine the amount of risk and work involved to maintain the health of a patient.  A patient’s RAF score is heavily weighted on HCC coding and documentation.

Medicare uses HCCs to reimburse Medicare Advantage plans based on their current members’ health.  HCCs are diseases or conditions organized into body systems or comparable disease processes that Medicare correlated with increased cost of care. Out of 72,748 ICD-10-CM codes, CMS identified 9,700 diagnoses associated with higher-than-average costs and then assigned them into 86 disease categories. Each of the 86 categories is then placed into a hierarchy of risk. The specific HCC category to which a diagnosis is assigned determines its contribution to the RAF calculation.

The Top HCC Categories Include:

• Major Depressive and Bipolar disorders
• Asthma and pulmonary disease
• Diabetes
• Specified heart arrhythmias
• Congestive Heart Failure
• Prostate Cancer
• Rheumatoid Arthritis
• Colorectal, Breast and Kidney Cancers

The underlying foundation of Value-Based Care (VBC) is not based on limiting care or quality. It’s about aligning optimal patient care with financial benefit – for the patient, for the doctor, and for the unsustainable cost of healthcare to our overall economy.

 Compliance is Now Incentivized

Though most TINs did a good job with meeting compliance in the past, due to complexity and the failure of vendors and health plans to provide TINs and their providers with the proper expertise, tools, and/or training, most are NOT meeting RAF compliance benchmarks and targets.

Administrators even boast about their robust risk adjustment, abstract coding teams, QA audit teams, and provider education. Unfortunately, too many are still apathetic about verification and action needed, because up until now, fully meeting requirements has not amounted to any significant increase in revenue. This has now changed.

So, now when ownership, boards, and/or stakeholders ask why your TIN’s reimbursement has been reduced or why you failed to maximize reimbursement and no one can explain why or do anything about it, ignorance or apathy will not be an accepted excuse. Don’t let this to happen to you!

You require a tool that empowers you with instant access to the information and data you need to manage and code each patient’s specific diagnoses – as well as create the documentation that supports the coding. In addition, help with negotiating better payment terms from your MA plans.

MA plan providers need a professional service that delivers results which achieve improved compliance, patient RAF Scores, patient attribution, Quality Scores, increased billing encounters and reimbursement, enhanced clinical support, outcomes, patient satisfaction, and cost reduction.

Hospitals and physicians are paid by MA plans and ACOs based on patient RAF Scores. It’s a fact that physicians struggle with having enough time to complete MA plan/ACO requirements related to the redocumentation of diagnoses. This can negatively impact the accuracy of patient RAF Scores.

To drive higher reimbursement, providers often seek to identify diagnoses which will result in higher patient RAF Scores. This requires focus on the coding of a patient’s diagnoses, and not necessarily on how well each condition is being managed. In other words, VBC models have created an overemphasis on coding, instead of on caring.

MA plan providers and ACOs use a variety of methods to increase patient RAF Scores. One approach is to review a patient’s medical record, typically after the patient encounter, to identify opportunities for “upcoding” a diagnosis to raise scores. For example, if a diabetes diagnosis can be coded as having neurological manifestations, the risk score will be higher, as will the reimbursement.

Just a quarter-point increase in a patient RAF Score translates into an extra $3,000 per patient per year to an MA plan or ACO and higher reimbursement and/or shared savings for the provider.

The platform works with and is dedicated to helping TINs and providers remain in control. They negotiate capitated agreements for clinics to quality for an increase in MA reimbursement through negotiated rates with their MA plans.

In addition, it can help your TIN choose and participate in the right plans and set up your support system, so your TIN is successful in increasing revenue without disrupting your current operations. In addition, help you optimize your participation with MA Plans while seamlessly integrating protocols that will streamline operations.

There are a lot of software products coming to and on the market claiming to help identify opportunities to optimize or manage risk, but in reality, they are just a veiled way of upcoding. They do NOT provide you with tools at the point of care for the patient; that is, properly manage, evaluate, assess, and treat a patient’s various conditions in accordance with the original intent of VBC: Improved Outcomes Through Better Management of Patient Health.

Our RAF Compliance Optimization platform will make efficient management of patient care as easy as 1-2-3. It will Reflect the health status of a patient population accurately and compliantly, which makes it a vital tool for all providers.

RAF Compliance Technology

The platform provides the top-tier support you require on Value-Based Care reporting and outcomes management. And with its EHR forensics, allows you to view provider level risk scores from prior years, as well as current average risk score. You will be able to drill down to the usage of unspecified and unsubmitted coding on all patients associated with a provider.  It will show the dates of a patient's last physical exam, next appointment, number of ER visits, number of diagnoses codes, the number of unspecified and unsubmitted coding, and the patient risk score.

Being able to view this information allows you to identify areas that need further improvement or education and is vital for getting a patient scheduled for Chronic Care conditions that need to be maintained and documented for improvement of the patient’s accurate risk score.

So, if you’re looking to do more than check the compliance box, the platform will allow you to turn your compliance into a competitive advantage and higher revenue by developing services in line with CMS’s Medicare CCM Program.

To learn more, see our Medicare CCM Program Optimization webpage.

Again, HCC coding directly correlates to your patient’s risk scores. Specificity is key when it comes to HCC coding and documentation.  A provider must report on each patient’s risk adjustment diagnosis, and it must be based on clinical documentation from a face-to-face encounter. For HCCs to be successful, the doctor can accomplish documentation standards by utilizing four datapoints you must document for each patient:

1. Monitor signs and symptoms (disease process)
2. Evaluate (test results, meds, patient response to treatment)
3. Assess (ordering tests, patient education, review records, counseling patient and family)
4. Treat (meds, therapies, procedure, modality)

As the shift in healthcare continues to happen, our RAF Compliance Optimization platform shifts with it. The program application captures the importance of HCC coding and patient RAF scores. The HCC related analytics are intended to provide insights that will drive network and provider performance management on risk scoring as it relates to CMS and Commercial payers.

The platform is essential for the success of your Risk Adjustment program. It will significantly improve the communication of patient complexity and effectively predict patient healthcare cost utilization. Its financial impact is significant because it directly impacts the money your TIN receives from the largest single payer in healthcare, CMS.

In addition, you have the potential to significantly impact both healthcare outcomes for your patients and reimbursement for your TIN and its providers. It will allow you to act upon information immediately and create accurate documentation that reflects the health status of a patient population accurately and compliantly, and it supports patient diagnosis and satisfies potential Quality Care and CMS/MA audits. And this makes it a vital tool for all providers. 

Tech and Data Are the Keys to Success

A comprehensive clinical care approach to VBC, as opposed to an approach that focuses on the transactional coding of diagnoses to maximize risk scores - requires a solution that enables you to quickly see the status of any known or suspected condition.

The comprehensive RAF Compliance technology effortlessly navigates the complexities of patient diagnostics to optimize patient RAF Scores. The exclusive, compliance-focused intelligence retrieval technology guides credentialed intake providers through an infallible step-by-step validation process. This meticulous approach not only ensures precise documentation of each patient condition, but also informs you of the required assessment and treatment plans. The result shall be accurate and compliant RAF Scores that drive revenue growth. And with the platform handling oversight, scheduling, billing and/or billing assistance, your focus can remain on excellent patient care.

What About ACO Reach?

Relying upon an ACO REACH is less effective because you can’t drive the metrics needed to identify patient complexity, and thus assure a risk-sharing lift, without top performing Patient Outreach data. The performance metrics gathered from the platform will exceed those from an ACO REACH and provide a significant boost in risk shared revenue while lowering overall costs.

What About CMS Updates and Changes?

The platform makes all necessary updates based on the latest version calculations for the current and upcoming CPY. Modifications to HCC & ICD codes are kept up to date to ensure correct coding and reporting based on updated diagnoses. As rules evolve, so does the platform, keeping you always ahead of the curve.

The First Step is Patient Outreach

To achieve or maintain top RAF performance, mandated and incentivized assessments based on each patient treatment care plan and their medical necessity is the tip of the spear for meeting compliance and obtaining insights into patient complexity.

Unlocking Financial Rewards starts with a RAF Verification Analysis to determine the best course of action.A reasonable analysis fee applies.

We will utilize publicly available CMS data, and data you supply us from your ACO, MA Plan(s), Electronic Medical Records (EHR) system, Practice Management System, and/or other manual sources.

You should expect to spend an hour or two working with our team to extract the data points required. The research, analysis, and report effort will take several manhours to complete. Within two business days, we will be ready to discuss the findings and recommendations with you via a Zoom call and present the RAF Compliance Optimization Strategy Report. This report will identify any compliance gaps & vulnerabilities and provide the most effective recommendations and solutions.

Our RAF Compliance Optimization platform is the empowering solution that covers all steps required to validate and compliantly document diagnoses driving increased audit validation and success. It will “check-the-box” that achieves or maintains top-performance. Ensuring that the complete health status of a patient is compliantly documented will provide the TIN, physician, and Health Plan with revenue and reimbursement.

Understanding the financial implications of RAF Compliance helps in making the decision on whether to invest in optimization services or stay the course with your ACO, vendor, or your own efforts very easy.

Take a few moments to download our supporting materials.

• 2025 CMS RADV Final Rule Changes (pdf).
• CMS 2025 Rate Announcement (pdf).
• Advance Notice of Methodological Changes for 2025 (pdf).
• Diagnostically Connecting Data and Diagnoses (pdf).
• HEDIS Measure Subset Impacted Patient Engagement (pdf).

Our Provider Partner is the leading firm specializing in the processes of Patient Engagement, RAF Compliance, Medicare CCM Program, Healthcare Technology, Data Analytics, and Business Management Services for financial ROI.

They support thousands of independent and hospital-based physicians & clinicians, multi-TIN organizations, ACO members, and Medicare Advantage plan providers. They possess a knowledgeable team of people that handle all necessary tasks and provide frequent reporting and useful analysis.

In a 30-60-minute Zoom call, we will talk about the required analysis and the easy enrollment process.

Take a moment to download our NCND. Complete and email it to: support@livewellaps.com. Then reserve your Zoom call with us.

1. Click Here to download our Mutual NCND (pdf). We are NOT data miners. Your info will be kept strictly confidential. We will also be sharing proprietary and confidential information with you on the Zoom call.
2. Click Here to go to our Calendly page to reserve your Zoom call (complete the required fields and when asked “purpose of call,” click: RAF Compliance Optimization).