RAPS / EDS User Group Sets Out a Course

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:

  1. Determine the likely range of degradation in RAF scores attributable to the conversion m RAPS to EDPS
    1. Plans and risk adjustment business partners will test “revenue neutrality” with concrete data 
    2. This consensus evidence will demonstrate if EDS data will or will not drive  revenue neutral results  with RAPS
  2. Identify the most prevalent root causes of errors
  3. Share learnings on solutions and approaches to remediation
    1. Initiate a data driven dialogue among plans to develop best practices for EDS error remediation and  effective practices
    2. Identify collaborative opportunities that may be useful and beneficial in local healthcare service areas
  4. Track and report performance improvement to the RISE community.
  5. 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

 

 

 

Recommended Approach

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?

 

Future Phase:

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.


Tags: RAPS, EDS

Log on to Your Rise Account

Forgot your password?
Create an Account

Association Sponsors

Latest Posts

Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan....
Read More

Getting It Right: True North in Healthcare Reform

The movement to repeal and replace "ObamaCare" created so much political noise that clear thinking has been hard to come by. The 2010 legislation that created the marketplace for individuals and small business (the Affordable Care Act or ACA), has almost evolved into a political Rorschach test. The more that politicized options and alternatives to repealing, replacing, or repairing it were discussed, the harder it was to put into focus the original problems the legislation was designed to address. Nevertheless, the rancorous divisions over what needs to happen to fix problems in the individual insurance market remain a distraction from the real issue at hand: the cost of healthcare weighing down the economy and what we need to do to fix it. With all the intense debates swirling around this topic, an impression emerges that “solving the ObamaCare issues” is something that must be accomplished as an isolated matter, discrete and independent of other problems. The heated debates concentrate on the mechanics and tactics required to solve the "uninsured problem", the "under-insured problem", and for some, the federal budget problems created by the subsidies for low-income enrollees in these plans. This single-issue mono-vision obscures a reality that must be addressed. This perspective completely misses the fact that something is going on that is far more corrosive to the wellbeing of all of us as consumers of health care, as taxpayers, and as a nation: something that overshadows the tug ‘o war over ObamaCare. The critical and overlooked issue is that health care expenditures in the U.S are at least twice as expensive as other nations, which consume so much of the national economy...
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.

More

Upcoming Webinar

Successful and Meaningful Techniques for Integrating Risk and Quality Interventions

Quality measurement and risk adjustment regulations are increasing and the financial impact upon health plans is progressively driving accountability and influencing profitability through payments, penalties, and bonuses. To improve performance and optimize risk and quality payments, Health Plans need to streamline processes, employ best practices for data capture, and focus on strategic interventions that use a member-centric approach.  

Connect With Us

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