Since 2012, CMS has been transitioning health plans from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS). In its Final Call Letter of April 6, CMS announced that for the first time, it will use data from both RAPS and EDS submission in the calculation of risk scores for Medicare Advantage plans. Beginning with 2015 dates of service, CMS will weigh data from RAPS submissions and FFS at 90% and data from EDS submissions and FFS at 10%.
Some health plans are fully prepared for this changeover; others will need to make adjustments to ensure their EDS and RAPS submissions are in complete alignment, so they continue to receive full risk adjustment accuracy payments.
New software platforms can help, by giving health plans the ability to quickly process a high volume of claims with a lower rate of errors/omissions. Two types of systems in particular can be useful. The first is a comprehensive claims data warehouse and processor that supports CMS-mandated data submissions and cost reporting. This system should support integration of native-format data and should have strong data-quality oversight.
When evaluating these aggregation platforms, look for a product that can manage the entire RAPS process, from receipt of native data to comprehensive data validation checks, RAPS file preparation and financial reporting. Another feature to look for is the ability to create thorough reports that help you understand the characteristics affecting member’s risk scores and the associated CMS reimbursement.
The second system to consider is an encounter data processor that can quickly perform robust compliance checks, providing in-depth reporting and tracking, error review and financial analysis. The ideal platform includes an online editing tool that delivers secure web-based access so you can identify encounter data errors, understand the causes and correct errors for resubmission. Your criteria for this product should include user-friendly navigation, easy-to-understand error messages and real-time validation to speed up submissions.
Before selecting either type of platform, make sure it is CMS approved and ask the vendor about implementation times. Custom product development can take months, so look for established, hosted products that can integrate with your existing systems, allowing you to be up and running in a matter of weeks.