Overview
of RAPS (Risk Adjustment Processing System):
Initially, Medicare Advantage Organizations
(MAOs) have been responsible for validating, filtering and compiling the
diagnosis codes when creating RAPS files per CMS guidelines. Although CMS
reviews the RAPS submissions for duplicates and errors, it does not verify the
validity of the MAO’s filtering logic or the resulting list of diagnosis codes
at the time of submission. Instead, CMS relies on Risk Adjustment Data
Validation (RADV) audits to ensure that the submitted diagnosis codes are
supported by patient charts.
Part of this audit, CMS will send plans a
sample of previously submitted claims and plans must provide medical chart
documentation to justify the submissions. If they cannot, plans have to pay
major penalties. These penalties would be attributable to all plan revenue
based on the percentage of failure in the sample.
RAPS
to EDPS:
There is a significant change in the RAPS
process. Part of EDPS (Encounter Data Processing System), all unfiltered/unsent
encounter details will be submitted directly to CMS. CMS then applies the
filtering logic to extract the valid diagnosis codes from the data. It also
checks for the procedure codes (HCPCS), all these will be used to provide a
more accurate way for risk score calculation.
Now it is MAOs responsibility that data
submitted through EDPS are complete and accurate so that all diagnosis codes
reported are being accepted for risk adjustment by CMS. Otherwise, MAOs may see
lower risk scores and lower risk adjusted revenue compared to RAPS.
EDPS
Incremental Transition Plan:
CMS outlined incremental RAPS to EDPS transition plan, which effects from 2016. Beginning in payment year 2016, CMS will change the calculation for risk adjusted payments to MAOs by using encounter data submitted by MAOs along with RAPS and the payment calculation percentages (EDPS/RAPS) will be as follows:
CMS outlined incremental RAPS to EDPS transition plan, which effects from 2016. Beginning in payment year 2016, CMS will change the calculation for risk adjusted payments to MAOs by using encounter data submitted by MAOs along with RAPS and the payment calculation percentages (EDPS/RAPS) will be as follows:
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10/90 percent split in 2016
●
25/75 percent split in 2017
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50/50 percent split in 2018
●
75/25 percent split in 2019
●
100 percent EDPS implementation in 2020
Challenges
EDPS system is complicated than RAPS, EDPS
needs all the diagnosis data which were not mandatory in case of RAPS and it
requires significantly more edits and CMS applies their own filter logic which
makes it difficult for the payer to get their claims accepted for processing.
Obviously, the first goal for a payer is
getting the claims accepted by CMS, so they have a record of the claim
transaction. To do this, health plan requires a system to perform,
●
Processing of all edits published by CMS, so
the organization can pre-filter and identify whether CMS will accept the
submission before it is submitted.
●
MAOs rely on claims data for submission of
both RAPS and EDPS as every claim includes all possible diagnosis codes for the
encounter. There are cases, risk scores are artificially decreased resulting
from provider billing practices.
●
Solution to submit all variations of
encounters including: standard, capitated, void and adjusted, chart linked and
unlinked, and deleted, as well as encounters from atypical providers
●
Claims which are denied by CMS will not be
included in the risk score. Organizations to prevent denials by enabling them
to correct inaccurate or incomplete claims before they’re sent to payers.
●
As encounters data will be sent in HIPAA ANSI
X12 5010 EDI 837 format in EDPS rather than the RAPS format. This will increase
the complexity as the ANSI X12 contains more than 1700 fields which need to be
sent for a single transaction.
●
Process CMS responses to claims transactions
(TA1, 999, 277CA, MA-002, & MA-004)
Another biggest challenge for health plans is
to reconcile RAPS submissions with EDPS against CMS processed responses to make
sure all RAPS and EDPS diagnosis codes and statuses are same and to identify
missing HCC (Hierarchical Category Condition) codes, also to correct
inaccuracies in both the submissions. To improve CMS acceptance rate for RAPS
and EDPS, health plans would need a solution to,
●
Streamline the reconciliation of RAPS with
EDPS to identify missing HCCs
●
Solution to identify and prioritize all errors
with the highest HCC impact
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Reporting of EDPS and RAPS outcomes to enable
HCC reconciliation between both submissions
●
Member level dashboards to show RAPS and EDPS
diagnosis codes and statuses
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Workflow system to – Prioritize submission
errors and assign error work queues by priority, with an intuitive
auto-assignment
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