What gaps are in your RAF????

DOJ:  Tue May 2, 2017:     United States intervenes in FCA against a Medicare Advantage Plan for mischarging the Medicare Advantage and Prescription Drug Program.



What the heck does that mean?  It means (in Medical Coding Language) that the diagnosis code (ICD 9 or ICD 10) used for the beneficiary- enrolled in that Part C Program might not have been documented / found in the provider chart note for the time frame required by CMS. Or… That the beneficiary did not have that condition / diagnosis at all.  Or… That the Plan perhaps added diagnosis codes that did not pertain to that patient (s.) Various scenarios.


Why does that matter? There are about 9,000 ICD- 10 diagnosis codes (out of a total of 68,000 ICD- 10 codes) that have a weight assigned to them by CMS.  These 9,000 codes are grouped into Hierarchical Condition Categories (HCC).   Each diagnosis code in these HCC groups have a weight assigned to them based on the severity of the diagnosis (just how sick the patient really is.)  For example, a HCC weight for Secondary Malignant Neoplasm of Right Lung has a weight of 2.484, whereas Primary Hyperparathyroidism has a weight of .245.  The weights of these HCC diagnosis codes are added up for each patient during January 1 through December 31 each year (resetting on January 1st again for the next year.) This cumulative weight or score of these HCC diagnosis codes are referred to as the Risk Adjustment Factor (RAF.) The higher the score usually means that the patient is very sick with many complications, thus the Medicare Advantage Plan (Part C) receives more money from CMS in subsequent years to take care of the beneficiary in that geographic area.  There is also a weight assigned for the patient age, gender, disability status, geographic area and living quarter status / institutionalization status.

We will start to see other FCA cases such as this going forward because there is a lot of money that is given each year to the Medicare Advantage Plans across the United States.

I hope this was simple so that everyone could grasp the broader concept. This case can be found at the DOJ website: https://www.justice.gov/opa/pr/united-states-intervenes-false-claims-act-lawsuit-against-unitedhealth-group-inc-mischarging  


Jacqueline Nash Bloink, MBA, RHIA, CHC, CFE, CPC-I, CPC, CMRS
Healthcare Compliance and Fraud Specialist


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