The Centers for Medicare and Medicaid Services’ (CMS) shift in the risk adjustment submission process from Risk Adjustment Payment System (RAPS) to the Encounter Data Process System (EDPS), isn’t a new challenge for health plans.
In 2015, CMS weighted submissions based on a blend of 90 percent RAPS and 10 percent EDPS scores. In 2017, CMS dialed back the requirement to 75 percent RAPS and 25 percent EDPS payment determinations.
Now, in a surprising move from CMS, the 2018 split further decreases the prevalence of EDPS in overall risk scores. This means that for the foreseeable future, this dual-submission system is here to stay – as are the complexity of reporting and challenges with reconciliation. Though there is no doubt that RAPS will eventually be phased out, it continues to be a waiting game.
If MAOs can’t ensure the accurate, complete and timely submission and reconciliation of both forms of risk adjustment. The result is missed deadlines, inaccurate risk scores and most critical, a substantial amount of revenue left 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 analysis of response files. However, prioritized exception management workflows can help the health plan identify the exception files that are most financially impactful to the organization (the bottom line), correct errors and resubmit.
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.
The dual-submission state of mind is not going away. Health plans need a consolidated submission and response reconciliation system that is capable of accurate and timely submission of both 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 real-time intelligence with up-to-date data on risk factors and a reduction in coding and care gaps. And let’s not forget that the cumulative effect of these capabilities is more accurate risk adjusted revenue integrity.
A single system approach, where all submissions and reconciliations are handled by one platform, is the most effective solution to overcome these logistical hurdles. RAPS and EDPS each have their own intricacies, and the organizational strain to overcome them independently is significant. One dashboard that displays all applicable information, submits risk adjustment regardless of system and manages the necessary exceptions will ensure MAOs thrive. Every day that MAOs continue to submit into separate systems will put them even further behind their competitors.
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