RAPS / EDS User Group Report

What impact will come with the migration from a RAPS-based RAF score to an encounter data-based RAF score? 


The RISE User Group aims to find out the answer to this question.  It involves complexity that is difficult to appreciate until you dig in deeper.  There are a lot of variables that cause different healthplans to come to different conclusions.  Here are some of the key moving parts:

  1. RAPS uses only 5 data elements to qualify for acceptable data submission while EDPS is aligned with the 5010 claim form of 37 data elements, which presents a lot more hurdles to pass for getting acceptance. 
  2. RAPS excludes a lot of services as ineligible for inclusion (such as labs, skilled nursing, etc.) while EDPS takes it all in. RAPS allows for supplemental data submissions to beef up its comprehensiveness and accuracy. In contrast, EDPS is primarily encounter-based (or claims- based), but EDPS allows retrospective and prospective chart reviews to augment the data from claims. 
  3. Depending on the filtering logic employed by the healthplans for both approaches, there can be a wide divergence in the percentage of diagnoses accepted

In addition to all these variables, we share further challenges getting adequate diagnoses captured.  When you take an end-to-end process review, there are several places where robust diagnosis capture gets watered down.  “Think of this as a hose”, as Behzad Mohazzebi1 famously said, “and let’s count the leaks”. Some examples:

  • The provider office billing systems, complying with the 5010, can only accept 12 ICD codes
  • The 837 submission abides by this restriction and, in order to gain a full set of diagnoses for truly complex patients, multiple 837s would be required.  However, that sets up claims processing duplicate flags at the payers’ end and would also require some special programming when submitting more than 12 ICD codes to EDPS as plans would be required to LINK claims together.
  • The handoff to billing services often result in truncating diagnoses, as do clearinghouses and other intermediate hands in the process
  • Hospital billing systems can often truncate the rich set of diagnoses that their coders extract from medical records
  • The claims systems at healthplans and insurance companies also have been found to frequently drop diagnoses because they are old systems that were not designed to accept a large number of diagnostic codes

The User Group hopes to begin tracking and reporting as testing of EDS submissions progresses.  We are expecting to gauge the level of data rejection, the types of filtering logic pursued by the plans, and root causes discovered in the process.  We are publishing a worksheet that is being used as the initial data collection tool for any RISE members to view.  Whatever we find as we work on this, we plan to publish and share in a transparent manner.  All Medicare Advantage Organizations are invited to join the group.  However, it may also be of interest to those with ACA-Marketplace products, since that will be entirely an encounter-based risk adjustment program.  

Download the Excel Spreadsheet we are using for data collection:  click here to download first page  second page  third page


1 Behzad Mohazzebi, founder of DCA, now part of Altegra Health

Categories: Risk Adjustment

Log on to Your Rise Account

Forgot your password?
Create an Account


Latest Posts

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ...
Read More

Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago....
Read More

Upcoming Conference


Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.


Upcoming Webinar

The Impact of Quality Incentive Models in Medicaid Markets


Thirty-one of our fifty states now have Medicaid managed care, and several markets are expected to implement managed care in the next few years. More than $160B in Medicaid spending occurs through the Managed Care Organizations. As more and more states seek to do more with less, increasing accountability for health quality outcomes is placed on health plans. Join this webinar to learn the typical quality payment approaches states use, issues often faced by health plans under each model and what states are expected to do with payment models tied to quality performance in light of near term Medicaid reform efforts.


Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.