Working on the EDGE – Understanding EDGE Server Submissions

June 30, 2015 Inovalon

Now that the data submissions for 2014 have come to an end and health plan issuers await responses from HHS on discrepancy reporting and final payments, it’s important to look back at the events of the last couple of months.

EDGE server submission began in December 2014, which was 11 months later than the expected start date. Software development had been in progress since 2013; yet there were limited and intermittent instructions, no proper data, and no EDGE server available for testing.

However, in the last five months, tremendous progress was made toward continually adapting the solution to the rapid changes within the EDGE server environment. Submission cadence and generation of risk adjustment/re-insurance reporting increased from once a month to three or four times a month, as a result of changing CMS requirements and ongoing data corrections. The number of reports originating from the EDGE Server grew from half a dozen to nearly two dozen.

Software development can be a complex cycle with many interdependent components

Software development can be a complex cycle with many interdependent components.

Because submission testing was not possible until December 2014, health plan issuers and TPAs had to continually adapt to changes and updates implemented on the EDGE servers. As a result, a number of unknown issues affected the data submission process. CMS worked with all stakeholders, including Qualified Health Plan issuers and TPAs, to identify and resolve many of the issues.

Given recent activity, health plans and TPAs should continue to remain flexible in the face of change. It will be necessary for health plan issuers to rely on sophisticated software with a strong foundation that can sustain rigorous submission cycles and adapt to evolving requirements. Nonetheless, the efficiency of the software is dependent on obtaining accurate information in a timely manner.

Moving forward, it’s important for health plan issuers to conduct a trial of the end-to-end submission process in an EDGE Server test zone, which is an exact replica of the production zone. Testing will enable health plan issuers to make any necessary adjustments before submission deadlines approach.

In regard to the actual EDGE server submissions, health plan issuers should weigh the cost and benefit of building versus buying a solution. From an organizational standpoint, the health plans should assess their prior experience, flexibility, staff expertise and resources to manage the EDGE server submission process within a rapidly changing regulatory and technical environment, to determine if they can manage the process on their own.

If an organization is considering an outsourced solution, some of the key characteristics of the software in evaluation would include the following:

  • Flexible – adaptable to change and scale as needed
  • Proven – fully tested in EDGE server test zone
  • Automated – if not fully automated, determine the level of manual intervention required
  • Standardized – if customization is necessary, determine the level

Overall, the EDGE server is a very complex extract transfer load (ETL) process that requires an intelligent and adaptable solution that can identify gaps and issues, while taking into consideration the transactional nature of the data and continually changing regulatory requirements.

Stay tuned for our next blog post on EDGE server submissions.

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