The monthly payment that a Medicare Advantage Organization (MAO) receives from the Centers for Medicare & Medicaid Services (CMS) increasingly depends on the thoroughness and accuracy of the MAO’s encounter data.

CMS is transitioning from its Risk Adjustment Process System (RAPS) to its Encounter Data Processing System (EDPS) as it seeks to base risk adjustment payments on more detailed records.

The portion of a MAO’s risk score that is determined according to data from EDPS will rise from 10 percent for payment year 2016 (for 2015 dates of service) to 25 percent for payment year 2017 (for 2016 dates of service). The percentage will gradually rise to 100 percent for payment year 2020 (for 2019 dates of service), when RAPS will no longer be included.

As an MAO, you must ensure that your encounter data is accurate in order to preserve, or perhaps increase, the amount of your monthly risk adjustment payment. However, verifying its accuracy may be challenging, particularly in comparison with RAPS, which is saying much given that efficient risk adjustment can already help health plans generate millions of dollars in incremental revenues by reporting the correct hierarchical condition category (HCC) codes.  

EDPS has thousands of more codes than RAPS. This allows for a more detailed depiction of the patient’s condition and the care provided but it also presents opportunities for MAOs to lose reimbursements. Failing to use the right codes could cost you.

Here are five ways to maximize revenue as you transition from RAPS to EDPS.

1) Learn the differences

You are likely accustomed to filtering your data before submitting risk adjustment eligible diagnoses in a minimum data set to the RAPS. But now that MAOs are submitting detailed encounter data, CMS will filter, or extract, diagnoses submitted to the EDPS that are eligible for risk adjustment.

CMS has finalized the filtering logic that extracts risk adjustment eligible diagnoses from encounter data records for use in calculating risk scores. Avoid rejections that could lower your risk score, and thereby potentially your monthly payment, by reviewing the CMS logic for differences in how EPDS handles records for inpatient, outpatient and professional encounters. Learn what  is required to substantiate diagnoses.

2) Look beyond the usual

You are likely accustomed to checking your RAPS data for valid diagnosis codes and enrollment information. And, you should continue to run these checks as you transition to the EDPS. But the current procedural terminology (CPT) codes that are reported to EDPS add a layer of complexity. Increase your percentage of acceptable diagnosis codes by confirming that your EDPS data passes National Correct Coding Initiative (CCI) edits.

3) But still watch for duplicates

The EDPS routinely receives multiple submissions of encounter files with duplicate data elements, according to a CMS presentation on risk adjustment encounter data. This causes duplicate validation edits on the submitter’s MAO-002 Report. CMS recommends that MAOs take the following steps to avoid duplicate EPDS submissions.

  • Wait for receipt of MAO-002 reports to properly reconcile encounter data files.
  • Do not include previously submitted encounter data records (EDRs) in batched encounters.
  • Only submit adjudicated encounters with changes in data from the original encounter data submission.

4) Allow more time

CMS also warns that the submission of encounter data, processing, and edit reporting in the EDPS  requires more time than in the RAPS. “To provide sufficient time for organizations to receive edit reports and submit corrected EDRs before the deadline, CMS strongly encourages organizations to submit EDRs (original, replacement/adjustment, and chart review EDRs) as soon as possible and to follow existing guidance on the frequency and timeliness of submissions,” according to the risk adjustment encounter data presentation for MAOs.

5) Review results

As you submit RAPS and EDPS data to CMS, track what you send and how it is received. Run reports throughout the process so that you can identify problems and develop solutions. Monitor data quality metrics carefully so that you can make timely adjustments. Compare your results in submitting to both systems and analyze the respective outcomes.

Evaluating the impact of errors in RAPS and EPDS and revising your processes and internal controls to better address and avoid costly mistakes will help you preserve your monthly risk adjustment payment.

Increasing the attention you give to EPDS data will be particularly important as it accounts for a larger share of your risk score in the future. Maximize revenue by smoothing your transition from the RAPS to EPDS with these five tips.

HEDIS Best Practices

About The Author

Reveleer is a healthcare-focused, technology-driven workflow, data, and analytics company that uses natural language processing (NLP) and artificial intelligence (AI) to empower health plans and risk-bearing providers with control over their Quality Improvement, Risk Adjustment, and Member Management programs. With one transformative solution, the Reveleer platform allows plans to independently execute and manage every aspect of enrollment, provider outreach, data retrieval, coding, abstraction, reporting, and submissions. Leveraging proprietary technology, robust data sets, and subject matter expertise, Reveleer provides complete record retrieval and review services, so health plans can confidently plan and execute programs that deliver more value and improved outcomes. To learn more about Reveleer, please visit Reveleer.com.