The Importance of Calculating Accurate RAF Scores

The risk adjustment factor (RAF) score is the risk score assigned to each patient in a risk adjustment payment model. Risk Adjustment Models account for multiple factors to calculate a RAF score which is the combination of both the demographic risk score and the disease risk score.

Demographic Risk Score:

  • The patient’s age and whether the patient is living in the community (e.g. with a family member or in his/her own home) or in an institution (e.g. in a nursing home or assisted living facility)
  • Whether the patient has a Medicaid disability and any interaction with age and gender

Disease Risk Score:

  • The weight associated with a hierarchical condition category (HCC) based on reported ICD-10-CM diagnosis codes
  • Interactions between certain disease categories
  • Interactions between certain disease categories and disability status

Once both the demographic and disease risk scores have been determined, the sum of both will result in the RAF score, which reflects the underlying health status (and expected costs) for the patient.

A RAF score of 1.00 indicates the patient is expected to use an average amount of resources. A score above 1.00 indicates high risk and therefore the patient is expected to use more than the average amount of resources. Conversely, a RAF score below 1.00 indicates low risk and less than average resource consumption is expected. A high RAF score reflects the most complicated patients, the highest consumption of resources, and the highest complexity of care needed.

A RAF score is calculated each calendar year for each patient. A healthcare entity also has an average RAF score for a defined patient population, which can be a good indicator for resource allocation (similar to the inpatient case mix index). The accuracy of RAF scores is tied to accurate and complete capture of chronic conditions that correlate to HCCs. For risk adjusted patient populations, understanding and ensuring accurate RAF scores is the key to accurate reimbursement.

Need help evaluating or capturing accurate RAF scores? UASI has helped clients across the country ensure accurate risk adjusted reimbursement. Contact us now at to get started.

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