How CoxHealth and CorroHealth Improved RAF Accuracy, Unlocked $12M in Revenue, and Enhanced Value-Based Care 

Accurate Risk Adjustment Factor (RAF) scores aren’t just numbers, they directly impact care quality, resource allocation, and financial success for healthcare organizations. However, mastering these scores can be a complex and daunting task. CoxHealth, a leading healthcare provider in southwest Missouri, faced this challenge head-on. As their value-based care contracts expanded, leadership suspected missed revenue opportunities due to inaccurate code capture. 

“Getting RAF scores right is no longer optional. It’s the key to ensuring better care for our patients and keeping our finances healthy,” explains Dr. Julia Flax, Chief Population Health Officer at CoxHealth. Realizing that building an internal infrastructure would take time, CoxHealth sought a partner that could ensure rapid performance improvement. They chose CorroHealth for their proven expertise in revenue cycle integrity. 

A Partnership for Precision: How CorroHealth Helped Close the Gaps 

To tackle the RAF accuracy challenge, CorroHealth initiated a comprehensive three-phased approach that produced rapid and meaningful financial results. 

Phase 1: Retrospective Reviews 

With the CMS risk adjustment data submission deadline just 30 days away, CorroHealth mobilized a global team, well-versed in CMS regulations, coding requirements, and timelines, to identify patients with previously uncaptured codes. The team rapidly reviewed the records of over 30,000 value-based care contract members to identify potential Hierarchical Condition Categories (HCCs). 

CorroHealth evaluated 24,178 patients with an eligible date of service. Within just one month, the team identified 11,419 new net HCC diagnosis codes, including no-code instances and higher HCC opportunities based on patient condition. 

CorroHealth identified new net HCC codes on 47% of the charts reviewed. The percentage of reviewed charts with new HCCs varied significantly across payers, as shown in the table above. Organizations aiming to improve RAF score accuracy can gain crucial strategy insights by assessing cross-payer findings. By examining historical charts, coding practices, and documentation patterns, CorroHealth uncovered common documentation gaps, such as chronic conditions not fully captured or instances where coding lacked the necessary specificity to map to appropriate HCCs. 

Phase 2: Concurrent Reviews 

Building on the insights from the retrospective review, CoxHealth recognized the need for both concurrent and prospective reviews. CorroHealth deployed a concurrent review system, integrated with CoxHealth’s Cerner EHR, and worked closely with six engaged physicians. Over 26,000 claims were reviewed, and 43.6% of those claims required coding edits, with 68% requiring additional HCC codes. 

This concurrent review process resulted in significant financial gains, increasing CoxHealth’s per-patient reimbursement by $179.33, equating to an estimated $3.4M in additional monthly revenue. The review also highlighted missed provider opportunities in 64% of the code reviews, helping guide future provider education. 

Furthermore, 4% of codes removed from the system fell into the OIG audit target list, likely preventing $350K to $1.1M in audit fines. 

Phase 3: Prospective Strategy 

Informed by the retrospective and concurrent reviews, the third phase focuses on prospective reviews. CorroHealth will leverage data-driven insights to improve coding accuracy during the initial encounter, reducing the need for post-visit coding adjustments. By educating providers and aligning documentation practices with coding requirements, CoxHealth aims to sustain long-term improvements in RAF score accuracy and financial performance. 

This phase includes ongoing education for providers to ensure that chronic conditions and other complex diagnoses are fully captured during patient visits. The deployment of prospective EHR reviews will allow for real-time identification of coding gaps, further enhancing the accuracy of RAF scores. 

Results & Next Steps 

CorroHealth’s expedient retrospective review uncovered 11,419 new or more specific HCCs, increasing CoxHealth’s overall RAF score by 0.138. The financial implications of these findings are substantial. Each new/specified HCC code increases a patient’s risk score and the overall RAF score, equating to $8M to $12M in higher reimbursement per month for patients covered under value-based contracts. 

Additionally, the following table illustrates the improvement in per-member per-month (PMPM) reimbursement after the coding review: 

The concurrent reviews led to coding edits for 43.6% of reviewed claims, with an average HCC weight of 0.16. It’s estimated that these results will increase CoxHealth’s per-patient per-month reimbursement by $179.33, leading to an additional $3.4M in reimbursement for the organization. If the 4% of codes removed had not been adjusted, audits could have resulted in $350K to $1.1M in fines for CoxHealth. 

CoxHealth and CorroHealth are now well-positioned to deploy an informed approach for prospective reviews and provider coding education, leveraging data-driven insights to build a culture of process improvements in coding workflows. This partnership exemplifies the potential to navigate the complexities of value-based care by combining clinical expertise with specialized coding knowledge, paving the way for sustainable improvements in both financial performance and patient outcomes. 

Whether you want to learn more or you are ready to get started, let’s talk.