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