The Transition from RAPS to EDPS

The comments have rolled in, and the concerns regarding the transition from Risk Adjustment Processing System (RAPS) to Encounter Data Processing System (EDPS) have been heard. The final Medicare Advantage Call Letter was released on April 3, 2017, and it contained a surprise on every page that was turned.

The struggle with the transition from RAPS to EDPS is not a new topic. At every conference, meeting, or hallway conversation that involves people working in risk adjustment, undoubtedly you will hear one of them start talking about the struggles with implementing EDPS. The up-and-coming way to send information to CMS has turned into a data submission nightmare. As referenced in a previous blog posted on March 1, 2017, titled “The New World of Data Submissions,” the Centers for Medicare & Medicaid Services (CMS) had anticipated, for the 2018 payment year, EDPS and RAPS would be weighted evenly at 50%. Much to everyone’s surprise, the weight for EDPS did not increase, in fact, it decreased. RAPS will be weighed at 85%, and EDPS will be weighed at 15% for the 2018 payment year.

RAPS_jessica table

The table clearly depicts the transition from RAPS to EDPS is taking a step in the wrong direction. Does this mean EDPS might eventually be dissolved because of the complexities that exist? Probably not.

What is does mean is CMS realizes getting an accepted 837 claim through EDPS is much more complicated than they originally anticipated, and the financial impact health plans are seeing is staggering. Double-digit percentage reduction in payments is what is being seen across the country. Those types of percentages are hard to ignore. So CMS took a step back to allow another year to refine processes, not just for health plans, but also for themselves. The MAO-004 report is supposed to be the backbone of the EDPS risk adjustment filtering logic to provide health plans visibility to the claims CMS selected to be utilized for risk adjustment. So far, this report has been questionable at best.

Every health plan that works with Medicare Advantage has been given an early Christmas present from CMS. They need to ensure they are treating it as such and use this year wisely to understand their EDPS process, and not just from the 50-foot view, but from a functional day-to-day process. Truly understanding their own internal data flow of how this information is being reviewed and distributed throughout the company then ultimately being sent to CMS. Developing internal controls, validations, and data reconciliations are important pieces to have in place to ensure accurate payments and reduce risk during a Risk Adjustment Data Validation (RADV) audit.

Lastly, a well-balanced partnership between risk adjustment operations and IT is required for EDPS to ever be successful. EDPS is a highly technical process that can only function properly with the added support and knowledge from risk adjustment subject matter experts. So even though it’s a technical process, the business unit handling risk adjustment operations needs to ensure they are closely aligned and providing the needed requirements and expert business knowledge to IT and testing the end result that is built.



Gorman Health Group’s Summary and Analysis of the Final Rate Announcement and 2018 Call Letter for Medicare Advantage and Part D is now available. Download now >>

Selecting the right partners and implementing the right tools to produce valuable and actionable data will allow clinicians and health plans to prioritize interventions, stratify the populations they are managing and identify those most at risk. Contact us to learn how we can help your organization >>

The Gorman Health Group 2017 Forum Conference Brochure and Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.


Jessica Smith
Jessica Smith

Jessica Smith is Vice President of Healthcare Analytics & Risk Adjustment Solutions at Gorman Health Group (GHG). In this role, she is responsible for the execution and oversight of risk adjustment consulting services for managed care, provider practice, and commercial market clients, and leading and integrating cross-functional teams to ensure superior performance outcomes related to risk adjustment operations. Read more

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