Anyone who has ever done competitive distance running (5K, 10K, half or full marathon, etc.) knows the key to success is setting the right pace early. Too slow and you will lose too much ground that you will never make up. Too fast and you will fade long before the finish line.
Medicare Advantage Organizations (MAOs) are facing that challenge right now with the transition from the established Risk Adjustment Process System (RAPS) to the new(er) Encounter Data Processing System (EDPS).
One of the challenges is that EDPS requires organizations that participate in the Medicare Advantage program to collect more detailed encounter data than they did under RAPS. As with many things in healthcare, this is no small task. It requires not only more sophisticated analytics but also a culture change. MAOs used to doing things one way, or gathering a particular data set, will now be asked to gather increasingly more complex encounter data, once again shaking them out of their comfort zones and no doubt leading to even more head shaking and eye rolling.
No matter how clinicians or the MAO as a whole feels about it, however, making a successful transition is becoming more urgent by the day as the Centers for Medicare and Medicaid Services (CMS) will increasingly base more of its payments on EDPS.
Right now it's like the starter's gun just went off. In 2016, just 10 percent of an MAO's risk score for services delivered in 2015 was based on EDPS. For 2017, CMS moved that up to 25 percent, and in 2018, based on the most recent letter, the split will be 85/15 in order to "provide payment stability." Prevailing wisdom is that this is just temporary relief, with CMS still intending to move toward the retirement of RAPS and eventually for payment for services to be fully based on EDPS.
So while it may seem to be a long way off at present, in health IT years this is practically tomorrow. MAOs that don't pick up the pace right now may find themselves falling short of the finish line. And there's a lot more at stake than a medal on a ribbon. In fact, given the large dollars at stake in Medicare Advantage programs, failure to complete the transition could have a crippling financial effect.
Here are some steps you can take to make sure you remain on-pace for the win:
1. Make a thorough comparison of the data you're generating for RAPS versus the data that is required for EDPS to determine what is lacking in the latter. Don't just look at what's required for this year, but look ahead as well. You don't have to finish the transition in 2017, but if you can work ahead a little it will help ensure you're prepared for any unexpected issues that may come up in the future. The goal is to provide transparency and a plan to minimize the discrepancy between RAPS and EDPS to < 5%.
2. If you do discover areas where EDPS data is missing, the next step is to analyze the data flow from the provider to the health plan to the government. You may discover that electronic data interchange (EDI) are employing data edits that inadvertently leave some diagnoses out of the EDPS system. Or you may find random diagnoses that are not being captured in EDPS. It could also be that specific billing systems may be missing certain diagnoses. Just as analytics can help you discover care gaps in patients, the right analytics can help you uncover data reporting gaps that you can fill to improve your EDPS reporting.
3. If you find data being submitted in an alternate format, ensure that it is being captured as a claim. Chart reviews are a great example of an alternative form of data that needs to be captured consistently.
4. If you discover any issues, don't just fix that instance. Instead, dig deeper to understand why the data wasn't captured properly initially or to discover the root cause. Taking this extra step of identifying exactly why a problem that required a correction and resubmission occurred will help you avoid the problem in the future – and ensure you're realizing all the risk adjustment revenue to which you're entitled.
Working through this checklist manually can be an arduous task, especially in MAOs with huge data sets. This is where having sophisticated data analytics can help MAOs remain on-pace to reach the 2020 deadline.
The right analytics make it easy to pinpoint issues and correct discrepancies as outlined in Step 2 above. They also can deliver the reporting that helps users and key executives see where the organization is relative to the transition to EDPS so additional resources can be deployed as needed. Add into that the support and training top analytics vendors deliver to help MAOs get up to speed and you're sure that your Medicare Advantage program will be a winner.
While it may be a cliché to say the transition to EDPS is a marathon, not a sprint, that doesn't make it any less true. By jumping in with a sense of urgency now, MAOs can ensure they move forward at a comfortable pace, with enough of a kick left at the end to ensure they cross the finish line in plenty of time to reap the financial rewards EDPS will bring.
Tom Peterson is the Senior Vice President for Care Optimization and Adjustment at SCIO Health Analytics®, an organization dedicated to using healthcare analytics to improve clinical outcomes, operational performance and business results.
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