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how to navigate RAPS-to-EDS revenue expectations

November 20, 2017

In the 2017 payment year, the 25 percent Encounter Data System (EDS) contribution and its impact on risk scores and associated revenue have challenged Medicare Advantage (MA) plans, which have much more experience submitting Risk Adjustment Processing System (RAPS) data. The difficulty of submitting data via EDS and getting the Centers for Medicare & Medicaid Services (CMS) to accept has thwarted effective management of revenue expectations. Through RAPS-versus-EDS comparative analysis and some strategic planning, however, MA plans can overcome these difficulties.

Verscend RAPS and EDS Management
streamlined CMS submissions to ensure accurate reimbursement

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Here’s an example. A health plan approached Verscend in April 2017, concerned about a 10 percent drop in its EDS risk score based on its Medicare beneficiary file. We put our analytic algorithm expertise to work, identifying several gaps in the plan’s submission data and processes that had caused its EDS risk score to drop significantly. The plan was able to correct these and submit to CMS before the May 1, 2017 deadline.


Here are five tips to help you be as prepared as possible.

1. Identify where encounters are failing in your EDS submission.

By categorizing failing or missing encounters and attributing the revenue impact to each category, MA plans can prioritize and allocate their resources appropriately. Categories may include: 

  • EDS filtering differences: For EDS, CMS applies its own filtering logic to determine allowed encounters for risk adjustment. For RAPS, the plan identifies qualifying records based on CMS guidelines. Calculate the risk scores from each diagnostic source (RAPS, EDS, and source claims/chart review data), then complete both member-level and plan-level comparisons for each source.
  • Data quality problems: Determine whether you have any issues with data quality or system processing challenges.
  • File time delays: Although RAPS return files are sent within one to two business days, the MAO-004 return file is generated only once a month, so several accepted claim IDs will not appear until the subsequent month.

2. Minimize your number of unmatched chart reviews.

Remember, although there is no separate requirement for chart review under RAPS, plans must match their chart reviews to the corresponding encounter under EDS. During the 2016 payment year, Verscend clients derived 3 percent of their EDS revenue from unmatched chart reviews (versus 13 percent from matched chart reviews). However, there is a strong possibility that CMS will no longer accept unmatched chart reviews in the future.

3. Strengthen your pre-validation rules and take other steps to improve your acceptance rate.

Strengthen your pre-validation rules to improve your CMS acceptance rate and reduce potential re-work, ensuring that all your data elements will successfully pass through the CMS filtering logic. Manage your member enrollment data by ensuring consistency between your member demographic and enrollment data files. Identify the most common data gaps leading to the largest HCC differences between your RAPS and EDS return data, and review the sources to determine whether those diagnosis codes weren’t included in the return file. Review your MAO-002 and MAO-004 reports for any discrepancies, and report them to CMS. Create and use the EDS test environment provided by CMS for your submission protocols.


Too much to handle? A vendor partner can help provide the analytic expertise you need to review your data processes.

4. Educate your providers and vendors to reduce data gaps.

Reach out to your providers and explain the impact of incorrect or missed coding. Train them on coding, billing, and other data submission best practices to improve future submissions and data quality. Among the most common provider data errors are missing or invalid tax ID, missing or invalid address or zip code, missing provider last name or facility name, and missing NPI. When your chart review vendors submit separate data extracts for RAPS and EDS to your plan, analyze the difference in HCC count.

5. Develop a scalable, repeatable plan of action.

Finally, put this all into motion by developing an action plan, executing it, and tracking it periodically as necessary to help you close the gap between your RAPS and EDS risk scores. Set measurable goals from month to month and monitor data flow across your systems.


RAPS and EDS management are just one component of Verscend's end-to-end, integrated Medicare Risk Adjustment solution. Interested in learning more? Sign up for a demo.

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As vice president of product at Verscend, Lesley drives the product strategy for Verscend’s end-to-end Risk Adjustment solutions, ensuring that we continue to deliver innovative and compliant solutions for our customers. She has more than 30 years’ experience in product and project management in the healthcare and pharmaceutical industries. Before joining Verscend, she served as senior vice president of product management at Halfpenny Technologies, a leading provider of clinical data exchange solutions for healthcare providers. She also previously served as senior vice president of care management products for TriZetto, where she was accountable for the quality, delivery, and support of the software solutions in the its care management portfolio, and she held multiple positions at Alere Health. Lesley is the co-author of 10 U.S. patents and has been published in 16 peer-reviewed scientific and clinical journals.

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