Most of us can appreciate the beauty and splendor of a beautiful sunset and all that it represents, such as the completion of a day's work and the passage of time. There is a sunset of a different type about to occur in the Medicare Advantage space, and although it may not be as spectacular as an actual sunset, there are things to consider to ensure that there are no dark clouds on the horizon that diminish the ability to see it clearly and have a positive experience.
Since October 2010, the Centers for Medicare & Medicaid Services (CMS) release of every Medicare Advantage (MA) Advance Notice of Methodological Changes for the Calendar Year AKA "the Advance Notice" has been met with trepidation by MA organizations (MAOs).
This trepidation stemmed from CMS' announcement in October 2010 of its intention to sunset the five data element Risk Adjustment Processing System (RAPS) format used by MAOs for submitting risk adjustment claims data to using the 5010 X12 837 encounter data format with many hundreds of data elements starting on January 1, 2012. Member risk scores would be calculated during the transition, which was expected to conclude by 2015, using a blend of EDPS- and RAPS-based data, with the percentage of risk score based on EDPS increasing year over year. By implementing the blending of EDPS and RAPS for risk scoring over time, CMS acknowledged that the transition to a 5010 X12 837 encounter data format with many hundreds of data elements from the five data element RAPS format would pose novel and daunting operational and financial challenges for MAOs for data completeness and accuracy; hence, the trepidation felt by MAOs with the annual release of the Notice and its announcement of the percentage of the risk score calculated from EDPS for the next payment year.
CMS had originally envisioned the sunsetting of RAPS to occur by 2015, but issues with data quality management and the industry's mobilization of people, processes, and technology to manage the transition took time to effectively implement. Therefore, during the transition MAOs were advised to monitor the gaps between EDPS and RAPS submissions to identify and address obstacles to submitting complete and accurate data. CMS' approach to improving data completeness and accuracy during the transition included incorporating the results of various GAO audits and OIG recommendations that prompted CMS to implement a number of metrics intended to improve data completeness and accuracy and to move the industry closer to the goal of risk score calculation based on 100 percent EDPS.
According to trending Centauri has done on its clients' EDPS Quarterly Report Cards, by which CMS compares its clients against their similarly-sized peers in the region, and Annual Operational Metrics, overall data completeness and accuracy has steadily improved to 98 percent or better submission acceptance rate for Professional, Institutional, and DME. Additionally, the gaps between EDPS and RAPS are now negligible for those MAOs with best practice data management and governance programs.
For the industry in general, acceptance rates are well above 90 percent, which bodes well for the full transition to EDPS-based risk scores with minimal impact on payment accuracy due to data completeness and quality issues. Thus, it was no surprise that the transition to 100 percent EDPS has finally been announced according to the recent release of the Advance Notice for PY 2022, and RAPS will finally be sunset after a long 10-year journey. Does this mean that all the people, processes, and technology that support RAPS can ride off into the sunset at the stroke of midnight on January 1, 2022?? No, not really.
In this article, we'll explore some important issues to consider as MAOs evaluate how to sunset their RAPS operations and ensure that their risk adjustment horizon is clear.
Timing of submission "sweeps" deadlines
Despite the fact that CMS announced a full cutover to RAPS for PY2022, which applies to 2021 dates of service, the way the submission deadlines operate make it unlikely that it is as simple as discontinuing the RAPS operational processes come January 1, 2022. The schedule as published below would seem to indicate that RAPS will truly not sunset until well after January 1, 2022, since PY 2022 risk scores are based on 2021 dates of service and are subject to initial, interim, and final deadlines. A question was posed to CMS at its informational call on January 19 about this and accepting RAPS past January 1, 2022, but CMS indicated it would issue further specific guidance later. CMS was also asked during the call about increasing the frequency of MAO-004 reports back to MAOs, which would be supportive of MAO efforts to address completeness and accuracy issues more proactively prior to sweeps deadlines. This would be especially critical as MAOs adapt to 100 percent EDPS risk score calculation post-RAPS sunset, and the MAO-004 reporting and reconciliation against the MAO-002s are the key to successfully monitoring for completeness and accuracy issues that could affect risk scores. This is particularly true for those MAOs who manage their own submissions as opposed to using a vendor partner. CMS agreed that increasing MAO-004 report frequency made sense for this reason and would consider the suggestion. As the industry awaits further guidance on the timing of the RAPS sunset and the possibility of increased MAO-004 reporting, MAOS should undertake a careful reevaluation of their risk adjustment data governance strategies, as discussed in the other points below.
Increased financial impact of incomplete/inaccurate data
It is very easy to quantify the financial impact of incomplete or inaccurate EDPS data on member risk scores, and then to aggregate this across the entire MAO membership and overall financial picture. So, if the operational risk adjustment strategy does not include an analyst or other resource whose sole function is to run these types of impact analytics, now is a good time to go ahead and evaluate RAPS-related people, processes and technology and perhaps plan to reallocate resources to increasing analytical power.
Addressing completeness and accuracy issues that prevent the acceptance of EDPS data and its subsequent availability for risk scoring will more than justify the cost of such an analyst. Although the below graphic illustrates the potential cost of poor risk adjustment medical coding, it is also illustrative of the potential cost of data that is not submitted to or is rejected by CMS for other reasons, thereby preventing the diagnosis data from getting to CMS and into the risk score calculation in the first place. There is nothing like this graphic to get the attention of those who are inclined to skimp on resource allocation to EDPS, or those who reason that the RAPS sunset automatically translates into resource elimination. It could certainly end up being the case that there is money to be saved in resource elimination, but only if there is already a sound data governance program in place for EDPS and risk adjustment in general as described in the next section.
Re-evaluation of data governance programs in alignment with industry best practices and metrics
By now, MAOs should have a robust data governance program that addresses the quality of the source member, provider, and claims data from which EDPS is sourced and close relationships with stakeholders from those departments. And if they don't, now is the time to establish those relationships since the sunsetting of RAPS means that data quality issues will have a much greater impact on risk scores than before as mentioned previously. Moreover, in June 2020 CMS began the much-anticipated Data Exchange Reporting after announcing in 2019 its intention to move toward the calculation of HEDIS measures on encounter data. This reporting heralded the arrival of the industry squarely at the intersection of risk adjustment and quality with its calculation of four HEDIS measures based on encounter data, and comparison of that calculation to the same four measures as calculated traditionally. MAOs found to have gaps between the two calculations were expected to submit to CMS a corrective action plan (CAP) for closing the gaps. Therefore, it is even more critical that complete and accurate encounter data is submitted and accepted at CMS. Since CMS now provides MAOs with a variety of reports that establish clear metrics, it makes sense that the MAO’s risk adjustment operational strategy should be built around these metrics as well as the EDPS Best Practices published by CMS via HPMS in June 2017. If an MAO doesn’t know what these reports are, does not have metrics in place that are based on these reports and/or does not know what the best practices are, then chances are good that the MAO does not have a sound operational risk adjustment strategy in place. No one should ever be surprised by what is on these reports, either, if the data governance strategy is working as it should be.
If after conducting a careful evaluation of all operational processes and financial reporting to ensure the proper sunsetting of RAPS in alignment with the published deadlines and applicable dates of service you discover that you need assistance in aligning your risk adjustment operational strategy to maximize financial success, reach out to a trusted partner like Centauri that can help you clear the horizon for a successful RAPS sunset and for a clear path forward to operational and financial success. Hopefully, now that the industry will no longer need to hold its collective breath over what the EDPS/RAPS risk score blend will be for the next payment year nor worry about parallel EDPS and RAPS submission and reconciliation, MAOs and their vendor partners can be more focused than ever on sound, best practice data governance strategies based on the effective use of business intelligence and technology.
About the author
Dawn Carter is a director of product strategy at Centauri Health Solutions. Her career in health care spans 25 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management and risk adjustment solutions for Medicare Advantage, Medicaid and Commercial health plans.
She also provides strategic advisory solutions and consulting services for revenue cycle operations. Prior to that, her experience spans all domains of health care including health plan claims and provider systems administration, and healthcare applications development. Her experience also includes multiple teaching engagements in medical administration, billing and coding.
Dawn holds a Bachelor’s degree in Business Administration. She is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.