Even though the year has just begun, the healthcare industry is looking ahead to what the next four years has in store. The Centers for Medicare & Medicaid Services (CMS) released its 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter (“2018 Draft Call Letter”) on February 1, 2017. As a whole, the 2018 Draft Call Letter had minimal updates, however, there were important impacts to risk adjustment.
One of the most controversial areas of focus for risk adjustment is around the data submission transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data Processing System (EDPS). When this transition began in 2012, the industry knew it would be a big lift to implement but had no idea how dramatically it would impact the risk score results and downstream financials. CMS began a “phase-in” approach in 2016 where the RAPS risk score was weighted 90%, and the EDPS risk score was weighted 10%, in calculation of the overall risk score. For 2017, the weight for EDPS was increased to 25%, and the weight for RAPS was decreased to 75%. CMS was clear it would increase the EDPS percentage each year until RAPS was phased out entirely. It was anticipated for 2018 EDPS and RAPS would be weighted evenly at 50%, but in the 2018 Draft Call Letter, no increase for the EDPS submission was proposed.
Throughout 2016, there was a large focus on reviewing the risk scores between the RAPS and EDPS submissions to ensure the risk scores between the two submissions were comparable. It became very clear in the early stages of analysis there were drastic differences between the risk scores that were calculated. Organizations became very concerned and outspoken about the EDPS data submission results. EDPS involves several more steps before a claim or encounter becomes an accepted record and is included in the risk score process. These additional steps allow the opportunity for data to be excluded which should otherwise be included.
Gorman Health Group has been conducting ongoing analysis between the RAPS and EDPS submissions and noticed the following, which should be areas of focus for each health plan in 2017 and going forward:
- Accuracy of front-end membership and claims systems
- Oversight of the data submissions process
- Establishing solid internal controls for checks and balances
- Thorough documentation and data flows
- Reconciliation of internal data, submissions, and errors
These areas are within the control of the health plan to improve the risk score accuracy between the two submissions. Each health plan should know how data flows through their organization and the different controls that are in place to ensure accuracy. Gorman Health Group has helped many clients achieve visibility into their own information through the use of Valencia™ and mitigate their risk during a Risk Adjustment Data Validation (RADV) audit.
When preparing comments to submit to CMS in response to the 2018 Draft Call Letter, be sure to evaluate what you control within your organization and what CMS controls.
Be prepared, and “know your data story.”
Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>
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