August 28, 2014
Background of the RISE sponsored RAPS / EDS revenue neutrality project:
CMS is using an encounter data submission (EDS) data extract to replace RAPS, and drive the calculation of HCC risk scores as well as related premium revenue for Medicare Advantage members. During the last two years, Medicare Advantage plans have been in a collaborative testing and implementation mode with CMS and they are currently in various stages of readiness.
The two approaches involve dramatically different levels of information involved in their respective processes: the RAPS system involves only 5 data elements, whereas the EDPS system utilizes all elements of a HIPAA standard 5010 format 837. During the current parallel processing time, MA Organizations are bringing up and fine tuning their EDPS submissions with feedback from CMS on errors uncovered in the process.
Purpose of the RISE sponsored RAPS / EDS revenue neutrality project:
Plans have expressed a great deal of frustration and concern regarding the level of editing that EDS transactions are undergoing. Over the last two years CMS has acknowledged some concerns, and edits more appropriately designed for fee-for-service data have been relaxed for managed care plans. Additionally, in the final notice for payment year 2015, CMS has announced that while EDS will drive 2015 payment, an accepted RAPS record will be acceptable if there is no accepted EDS record for an encounter.
However, EDS in its initial design was to be revenue neutral. No payment reduction was to be derived simply due to the change in format for the encounter data collection process.
Because it is likely and plans expect that the 2015 data collection period for the 2016 payment year will solely be in an EDS format and the more straightforward RAPS data collectionn will be “sunset”, now is the opportunity for plans to test the revenue neutrality theory with data.
There are several immediate goals of this project:
RISE views this situation as an opportunity to provide support to individuals and their MA organization employers to learn best practices in order to enhance the quality of the conversion for the benefit of their membership. RISE is in the unique position of forming a collaboration of peers from across multiple MA Organizations to:
- Determine the likely range of degradation in RAF scores attributable to the conversion m RAPS to EDPS
- Plans and risk adjustment business partners will test “revenue neutrality” with concrete data
- This consensus evidence will demonstrate if EDS data will or will not drive revenue neutral results with RAPS
- Identify the most prevalent root causes of errors
- Share learnings on solutions and approaches to remediation
- Initiate a data driven dialogue among plans to develop best practices for EDS error remediation and effective practices
- Identify collaborative opportunities that may be useful and beneficial in local healthcare service areas
- Track and report performance improvement to the RISE community.
- Provide data to CMS (potentially in collaboration with AHIP) designed to eliminate non value added error situations which plans may not be able to remediate
RISE has developed a steering group of subject matter experts and leadership to organize and guide the process. The larger working group will collaborate around sharing non-competitive information and experience in order to accomplish the purpose of this project for the benefit of the community of Medicare Advantage Organizations and their at-risk provider partners. This group will be composed of volunteers from the RISE healthplan membership community. This group will collect and report data on their experience with preparing for the switchover to EDS.
CMS Regulations on the EDPS error reports are still incomplete. CMS has targeted release of the MAO Reporting guidelines in October, 2014. A staged analysis is proposed to gather summary data from participating Health Plans while awaiting the release of CMS guidelines.
Participating Plans are asked to separately analyze HMO and PPO plan data to identify any variance in data results between types of plans
Staged Data Analytics Proposal and timeline:
RAPS and EDPS processing would be compared as follows
From all RAPS response files returned to your Plan through 9/5/2014, create a file of accepted diagnoses with dates of service 1/1/2014 through 6/30/2014. Include only those diagnosis codes which are included in the 2013 or 2014 HCC model.
From all EDS response files returned through 9/5/2014, create a similar file of accepted diagnoses with dates of service 1/1/2014 through 6/30/2014. Include only those diagnosis codes which are included in the 2013 or 2014 HCC model.
For each file; create a frequency count by dx of:
- Those dx that are accepted in both RAPS and EDS.
- Those dx that are accepted in RAPS and not accepted in EDS
For each file, identify the number of unique members who one or more diagnoses accepted in RAPS, and not accepted in EDS
Of the EDS HCC’s that are accepted in RAPS and not accepted in EDS:
a) How many and what % of total are 277 errors
b) Run a frequency by error reason
c) How many and what % are MAO errors
The analysis will attempt to answer:
1. What conclusions can we make regarding error remediation?
2. How can we share best practices among plans?
The Steering Committee and Working Group will evaluate how financial modelling for the 2015 payment year can be adapted to estimating the financial impact of the variance between the two models. As CMS publishes MAO standards, we plan to collect data on those error rates and reasons as well.