Simple facts related to Medicare Risk Adjustment Factors (RAF) and the Hierarchical Condition Category (HCC) model
Enrollment in Medicare Advantage has increased from 11.1 million patients in 2010 to 14.4 million in 2013
25 percent(25%)of all Medicare beneficiaries are enrolled in Advantage programs
In 2010 2/3 of all Medicare beneficiaries had multiple chronic conditions; 14% had six or more chronic conditions
The average base payment for each Medicare Advantage patient is $4,000.00
Correct documentation and coding aids in identifying patients who have a higher risk adjustment value and supports reimbursement to provide better care
A major portion of the capitated payment is based on the patient’s risk for future health care cost. This risk, the patient’s demographics, and sex establish a RAF score (Risk Adjustment Factor derived from the Hierarchical Condition Category (HCC) model).
Medicare Advantage plans rely entirely on the Hierarchical Condition Category for reimbursement.
Advantage plans must capture HCCs conditions annually. When documentation does not support the chronic condition(s), and no identification of HCCs has taken place, no reimbursement will be collected from Medicare.
If the chronic condition is not properly document and reported during the calendar year, the condition(s) will not be reimbursed and will be un- documented and treated without charge the following year.
Filing: You can “reach back” and file for reporting year 2013 until Jan. 2015 and recoup any RAF adjustments you are eligible for.
