As the industry focuses on the progress of MAOs as they transition to Encounter Data Process System (EDPS)-based risk scores and the effect on revenue, the industry must also consider the impact of the dual submission model.
Utilizing separate RAPS and EDPS submission systems automatically impedes the reconciliation process, and health plans lose insight into the “why” of risk adjustment scoring. Though there is no doubt that Risk Adjustment Payment System (RAPS) will eventually be phased out, for the foreseeable future, the dual-submission system is here to stay – so MAOs must correct simple missteps to grow financially and effectively manage member care.
MAOS can make immediate process improvements in two areas, the management of rejected encounters and the reconciliation of response files from CMS. Sadly, the impact of mismanagement hits the bottom line and leaves a substantial amount of revenue on the table. Too often, we see organizations relying on armies of people and massive spreadsheets as a solution to managing exceptions – including manual reconciliation and analyses of response files. However, prioritized exception management workflows can help the health plan identify the exception files that will have the greatest financial impact on the organization (the bottom line), and then correct errors and resubmit.
Many MAOs identify their biggest challenges as being data accessibility and visibility. Given the differences in the two formats, many organizations rely on two separate systems to handle RAPS and EDPS submissions. Deploying dual systems to manage submissions often results in cumbersome reconciliation and exception management processes and obscures visibility into the end-to-end encounter submission lifecycle. This lack of visibility also impedes the analysis of the percentage of submitted claims that generate encounter files.
Because dual-submission is not going away, health plans need a singular, consolidated submission and response reconciliation system – one that is capable of accurate, timely submission of RAPS and EDPS data, identifies data discrepancies, prioritizes exception through workflows and handles ongoing changes from CMS without impacting business continuity. This kind of operational change results in greater efficiencies and member insights, as well as actionable intelligence with up-to-date data on risk scores and a reduction in coding and care gaps. Let’s not forget the cumulative effect of these capabilities is more accurate risk-adjusted revenue integrity.
RAPS and EDPS each have their own intricacies, and the organizational strain to overcome them independently is significant. The future is a single system approach, where all submissions, reconciliations and exceptions are handled by one platform. It is widely known that this is the most effective solution to overcome these logistical and operational hurdles. A singular platform that prioritizes exceptions by revenue impact, ensures end-to- end visibility throughout the encounter lifecycle and streamlines RAPS and EDPS reconciliation—is required to help MAOs thrive. MAOs must stop viewing the ongoing encounter submission transition as a compliance checkbox, at best, and a revenue roadblock, at worst. They must view this transition as an opportunity to better align internal processes and better connect their encounter management operations to their risk adjustment scores. This is the key to success in protecting Medicare Advantage revenue and managing member care.