Most health plans are leaving money on the table with risk adjustment.
Not because of fraud. Not because of bad coding. Because of incomplete diagnosis capture — and no one checks until CMS reconciliation hits.
Here's how RAF scores actually work:
Two components make up every RAF score:
Demographic component — age, gender, enrollment status (community vs institutional). A 72-year-old female in the community starts at 0.379 before a single diagnosis is added.
Diagnosis component — each qualifying ICD-10 code maps to an HCC category, and each HCC carries a CMS-published coefficient. These add up. But hierarchies prevent double-counting — the most severe condition in each disease group wins.
The V28 shift most plans still haven't fully absorbed:
CMS moved from V24 (86 HCC categories) to V28 (115 categories) starting in 2024. The blend runs through 2026 — 33% V24 / 67% V28 in 2025, then 100% V28 in 2026.
V28 added significant weight to behavioral health and substance use disorder categories. Plans that haven't updated their coding workflows for V28 are systematically under-capturing RAF on their highest-cost members.
What a missed HCC actually costs:
Take a member with diabetes + chronic kidney disease stage 3. Under V28:
Diabetes with complications: HCC coefficient ≈ 0.302
CKD stage 3-4: HCC coefficient ≈ 0.289
Miss the CKD diagnosis in the annual coding sweep → lose 0.289 RAF points per member.
At a $900/month base rate: $900 × 0.289 = $260/member/month in underpayment.
At 1,000 members with missed CKD → $3.1M/year in lost revenue.
That's one diagnosis code. On one condition group.
The practical check every risk adjustment team should run:
Pull members with diabetes diagnoses (E10-E13 codes)
Cross-reference against lab results — HbA1c > 9.0 without a complications HCC is a red flag
Pull members on ACE inhibitors or ARBs without a CKD or hypertension HCC — likely under-coded
Check members 65+ without a mental health or behavioral health HCC against pharmacy claims for psych medications
Most plans find 3-8% of their member panel with actionable coding gaps on the first pass.
We built a free RAF score calculator to help teams model this:
Paste in age, gender, enrollment status, and ICD-10 codes → get the full CMS-HCC V28 RAF score with component breakdown and payment impact estimate.
No account required. Useful for:
Coding education and training
Scenario modeling before annual sweeps
Quick-checking individual member profiles
Understanding V28 vs V24 scoring differences
👉 Try it free: mdatool.com/tools/hcc-calculator
The Pro version lets risk adjustment teams model entire member cohorts, save and compare scenarios, and export RAF reports for actuarial review.
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