Strategies to Ensure Accurate Coding and Submission of Upstream Encounter Data

On Demand Webinar: Strategies to Ensure Accurate Coding and Submission of Upstream Encounter Data

October 22, 2020

On October 8th, GHG’s SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment, as well as steps you can take to ensure that your data is ready in advance of the submission deadline.

Our speakers shared their unique perspectives on the best strategies to deploy to ensure that your upstream encounter data is accurate, complete, compliant, and ready for submission.

If you did not get a chance to attend the webinar, click here to view the recording.

In this webinar…..

Some of the key questions answered in this discussion include:

  • What are the major impacts from CMS’ 2022 Advance Notice on the current regulatory environment? CMS is projecting the risk score impact of transitioning to the 2020 HCC risk adjustment model to be 0.25%. While the impact on MA risk scores being calculated using 100% encounter data is projected to have a neutral impact at 0.00%, the shift to EDS is very much driven by the complexities of the process, and our experience shows the impact could be between a 1-3% difference between EDS versus RAPS. – Jeff De Los Reyes, GHG
  • What are the potential risks for either revenue exposure or compliance exposure as plans move from RAPS to EDS? To avoid the risk of compliance exposure, it’s important to not only look for incremental revenue, but to also take a bi-directional look at both adds and deletes to ensure the data is complete and accurate. When it comes to revenue exposure, we’ve found that data leakage can lead to suppressed risk scores and result in an average of $35-$50 PMPY impact for both the MA and ACA markets. – Austin Bostock, Pareto Intelligence
  • How can plans proactively prepare to mitigate the undue burden that EDS can cause? One way to manage this process is by tracking encounters through the entire submission process (i.e., tracking the recipient of the claim from CMS all the way back to your EDW). Another major factor is timing. Many plans currently submit RAPS on a near-monthly basis, but it’s going to be critical to submit EDS just as frequently, if not more frequently than RAPS. – Austin Bostock, Pareto Intelligence
  • With front-end submissions being so complex, how can plans evaluate their readiness for remediating back-end EDS errors? The key to being successful with EDS is knowing your data. Plans must be able to identify where data leakage is most likely to occur, whether it be from receiving incomplete data from providers or potential errors with internal system processes. Conducting a RAPS/EDS revenue audit or an EDS gap analysis can identify these top errors and help plans prioritize remediation efforts. – Meleah Bridgeford, Episource

The answers to these questions and many more are discussed at length in our October 8th webinar titled, “Strategies to Ensure Accurate Coding and Submission of Upstream Encounter Data.” Click below to receive access to a recording of the webinar and explore the various insights from the panelists.

For additional questions and inquiries about how GHG can support your needs, please contact us.

2022 Advance Notice Part I Released, Heavy Focus on Risk Adjustment

On September 14th, CMS published the 2022 Advance Notice Part I, with particular emphasis on Risk Adjustment. One key takeaway from this announcement is that CMS will push forward with their plan to implement and fully phase in the use of 100% of encounter data using the 2020 CMS-HCC model. Read the memo here.

GHG and Pareto Intelligence will be published an in-depth follow-up article to the Advance Notice, which contains key takeaways and impacts for health plans. Read the article here.

Contact Jeff De Los Reyes with any questions.

CHART Model Team to Host Informational Webinar

The Community Health Access & Rural Transformation (CHART) Model team is hosting a webinar TOMORROW, Tuesday, August 18, from 1:00 – 2:30 PM EDT.

To promote better health outcomes for the approximately 57 million Americans living in rural communities, including millions of Medicare & Medicaid beneficiaries facing unique challenges (i.e., limited transportation options, shortage of health care services, and the inability to benefit from technology and care-delivery innovations), CMS is launching the CHART models to address the disparities by leveraging innovative financial and operational arrangements.

Centers for Medicare & Medicaid Services will offer a Community Transformation Track and an Accountable Care Organization (ACO) Transformation Track to test whether upfront investments, predictable capitated payments, and operational and regulatory flexibilities will enable rural healthcare providers to improve access to high quality care while reducing healthcare costs.

CMS anticipates that the Notice of Funding Opportunity (NOFO) for the Community Transformation Track will be available in September on the Model website. The Request for Application (RFA) for the ACO Transformation Track will be available in early 2021.

Register for the CHART Model webinar here:

CMS Resumes Parts C and D Program Audit Activities for 2020

CMS is resuming Medicare Parts C and D program audit activities for 2020. As of yesterday, all engagement letters for 2020 audits have been distributed. Contact Tina Bailey, CCEP with any questions or support with an upcoming audit.

Program audit info here:

OMB-Approved 2020 Program Audit Protocols

CMS has published the OMB-approved 2020 Program Audit Protocols, available for download here:

CMS also announced a possible reprioritization of the 2020 program audits in an effort to complete them later this year. Sponsors should review the new protocols and prepare for any changes in data reporting, process, etc.

Reach out to Tina Bailey, CCEP with any questions or help navigating the changes.

CY2021 Marketing Models, Standard Documents, and Educational Material

While we await the associated HPMS memo, CMS had uploaded the CY2021 materials to their website. You can preview them here:

Health Service Delivery Tables Deadline is Fast Approaching

CMS requires MA plans to maintain a compliant network at all times. We understand that your plan may have deployed your network analytic teams to support other functional areas due to the pandemic; however, the mid-June deadline to submit Health Service Delivery (HSD) tables for CMS review is fast approaching. Based upon the data in your provider and facility files, GHG can typically run a network analysis to review your plan’s adequacy in 2-3 business days, as well as support your HSD submissions.

Contact us today to perform this critical final check before the deadline.

CMS Publishes Revised COVID-19 Guidance

CMS has published additional guidance related to COVID-19 for MA and Part D sponsors, including expanded benefit offerings, telehealth information, Model of Care flexibility and more. This announcement revises and replaces an initial memo released on March 10.

Reach out to us at with any questions.

CMS Announces COVID-19 Mailbox for MA Plans

In case you missed it, CMS announced a COVID-19 mailbox for Medicare Advantage plans to submit policy and benefit related questions. View it here:

GHG’s experts are also here to answer any of your Coronavirus-related questions—don’t hesitate to reach out for support.

CMS Shares Key Information Surrounding MA Organizations & COVID-19

On March 10, 2020, CMS issued key information via HPMS memo on the responsibilities and flexibilities afforded to Medicare Advantage organizations and Part D sponsors related to disasters and emergencies resulting from COVID-19.

A declaration by the Governor of a State is one of the triggering events for the special requirements related to Part A\B and supplemental Part C benefit access.  Under 42 CFR 422.100(m) the requirements are in effect until the end of the date identified in the state declaration or for 30 days if no end date is identified.  To date, declarations have been made in at least 8 states.  We urge you to follow for specific information related to your state(s) of plan operation.

When the special requirements are in effect, the requirements for MAOs are:

  1. Cover Medicare Parts A and B services and supplemental Part C plan benefits furnished at non-contracted facilities subject to § 422.204(b)(3), which requires that facilities that furnish covered A/B benefits have participation agreements with Medicare.
  2. Waive, in full, requirements for gatekeeper referrals where applicable.
  3. Provide the same cost-sharing for the enrollee as if the service or benefit had been furnished at a plan-contracted facility.
  4. Make changes that benefit the enrollee effective immediately without the 30-day notification requirement at § 422.111(d)(3). Such changes could include reductions in cost-sharing and waiving prior authorizations.

We urge you to review the HPMS memo here. and follow for specific information related to your state(s) of plan operation.

Contact a GHG expert today with any questions or if you need assistance.