Risk Adjustment FAQs

Risk Adjustment Factor (RAF) is a Medicare-based program that assesses and maps out a picture of chronic conditions in the member population. It uses specific ICD-10-CM diagnosis codes that link to Medicare’s Hierarchical Condition Categories (HCC) model. Submission of these specific ICD-10-CM codes on a claim is how providers impact the RAF score of their patient panel.

RAF scores are used to assess a member population’s burden of illness and to establish an appropriate cost of care, ultimately affecting quality scores and shared savings arrangements.

As we craft a clearer picture of member population health, patients receive greater focus on preventive care and guidance through the care process, making patients healthier and better able to avoid chronic conditions in the future.

As RAF ultimately allows us to gain a better understanding of the health status of our member population, we may accurately identify and code chronic conditions. As a result, our ability to map effective treatment plans improves, and our patients may enjoy better health.

Risk Adjustment Factor (RAF) can have clinical and financial impact. The risk scores evaluate the burden of illness of patient populations and identify an appropriate cost of care for assessing, treating, and managing specific conditions. Therefore, the way providers apply ICD-10-CM codes to claims affects provider quality scores, the success of shared savings arrangements, and the amount of funding available to provide care advising resources to patients.