Risk Adjustment Factor

Building healthier communities involves more than treating patients who come to us for care; we wish to bring more members of our community to providers and deliver preventive care so patients don’t get sick.

Risk Adjustment Factor (RAF) helps us do that. Using the ICD-10-CM diagnosis codes that link to the Hierarchical Condition Categories (HCC) used by the Centers for Medicare & Medicaid Services (CMS), we are building in an accurate patient community profile to improve care and patient access to treatment. This requires that providers:

• See Medicare patients at least once a year
• Record treatment in the electronic medical record system
• Evaluate, assess and manage all coded conditions
• Enter specific and accurate ICD-10-CM codes

ICD-10 codes are applied to the patient claim, and Medicare then maps the patient conditions to the appropriate condition category, each of which has a unique risk score. Entry of specific ICD-10-CM codes on a claim is the only way to impact the RAF score of a patient panel.

Proactive Care and Payer Partnership Programs

The Proactive Care Program is a coordinated approach to improving quality of care and the patient experience. This clinical program helps to identify patient gaps in care and give providers the data necessary to address them.

Payer Partnerships allows us to help the members of Premier Health Plan and even more Medicare beneficiaries in our service area improve their health and well-being. We provide Care Advising services to our members to help them navigate their health care path, scaling our resources to impact our communities through more coordinated care.