Next year, the Centers for Medicare and Medicaid Services (CMS) will begin transitioning how it adjusts risk scores for beneficiaries of Medicare, Medicare Advantage, Medicaid and other plans. CMS will base 90 percent of the score on data delivered to the older Risk Adjustment Processing System (RAPS) with the remaining 10 percent based on the new Encounter Data Processing System (EDPS).
The main difference between the two systems is the EDPS requires a lot more data, including provider services delivered (covered or not), payments, NPI and provider addresses, and all the other elements included in HIPAA ANSI Version 5010. In other words, there’s way more room for error. To help ensure that this first financially meaningful EDPS process runs smoothly for your organization, we recommend following these five tips.
1. Identify errors before submission. To avoid the countless hours associated with data submission rejections, rework and re-submission, identify potential errors as much as possible beforehand. This preparation will save your team a lot of frustration in the long run.
2. Find the source. Once the errors are identified, you’ll likely start to discover commonalities, such as they all involve the same provider organization, diagnoses or services. Finding the source of the data errors can streamline the correction process this year and for future rounds of encounter data submissions.
3. Perform IT assessment. You’ll need to ensure that your IT systems can efficiently and effectively convert encounter data to the EDGE server format required by CMS. You don’t want to wait until it’s time to submit the data and face a potential delay or rejections due to incorrect formatting.
4. Bring in experts. Many payers plan to save time and improve submission results (i.e., increase risk scores) by retaining an encounters partner to assist with the process. The partner can also deliver analysis and reporting of the encounter data that can offer new insight into member risk-stratification that can help improve future financial performance.
5. Educate providers. After this first round of CMS encounter data submission, your organization will be able to educate providers about their coding, billing and other data submission practices to improve future EDPS submissions.
Additional Resource: Listen to our webinar recording, Top 5 Factors to Consider in Your Medicare/Medicaid Encounters Partner for 2016.