The RISE Risk Adjustment Policy Committee looks at the implications of the Centers for Medicare & Medicaid Services’ (CMS) plans to fully phase in the CMS-HCC model in 2022.

As RISE reported on September 15, CMS intends to fully phase in the CMS-HCC model in 2022: This is a change from the mix for 2021 of 75 percent of the risk score calculated using the 2020 CMS-HCC model and 25 percent of the risk score calculated using the 2017 CMS-HCC model.

RELATED: 2022 Medicare Advantage Advance Notice: CMS reveals plans to fully use encounter data for risk adjustment

Under the proposal for 2022, CMS will calculate 100 percent of the risk score using the 2020 CMS-HCC model. The industry is fully aware of this change, of course, but the implications of the shift in methodology still loom on the horizon, which concerns the RISE Risk Adjustment Policy Committee.

In recent deliberations, the Risk Adjustment Policy Committee discussed how Medicare Advantage Organizations (MAO) have taken various and disparate approaches to the multi-year transition away from a Risk Adjustment Processing System (RAPS)-based methodology to a fully encounter-based approach. For example, some companies have built parallel data handling tools, running RAPS-based claims data separately from their encounter-based data stream. Yet others collapsed those two data streams into one singular feed. Among those with separate and parallel processes, some plans may decide to retire the RAPS methodology to reduce some administrative costs incurred by maintaining two separate methodologies.  And therein lies a problem, according to the Risk Adjustment Policy Committee.

When the two data streams are collapsed and integrated into one, the MAO loses insight into the differences and gaps visible when using two separate tools. Because the encounter-only methodology will be the basis of payment adjustments, some organizations may hurry to cut the cord on the RAPS tools, losing the extra dimension provided by comparing and contrasting the detailed outputs and ultimate Risk Adjustment Factor (RAF) scores generated by each methodology. However, continuing to run both systems in parallel can highlight places where the Encounter Data Process System (EDPS) system fails to report certain encounters that previously made it successfully through a RAPS process.  This spotlight can enable the health plan to identify and remedy the failures in the EDPS capture process, at least for some period after the 2022 complete conversion takes place. 

Consequently, the Risk Adjustment Policy Committee encourages MA plans to continue running both systems simultaneously for a while to maximize the opportunities to fix the gaps in their EDPS RAF results.  Not only does this make sense for risk adjustment purposes, but it also has implications for other changes triggered by electronic data exchange, such as the HEDIS program migration toward Electronic Clinical Data System (EDCS).

The migration from RAPS to EDPS has taken many years and most MA plans have made significant progress compared to their early results in 2015. But this is not the time to abruptly halt the parallel approach to data stream management: the job is not fully complete and warrants continuing until the MA plans are satisfied with the EDPS-only results.