The Transition From RAPS to EDS: New Offering Helps Your Plan Calculate & Define Risk Level

In 2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent based on the RAPS files. With this transition, it is critical that health plans ensure that their RAPS files and Encounter files are in sync. Oh- and the vendors are on the hook for this too.

For some, the financial and operational impact of the transition from RAPS files to EDS files for risk adjustment is still a mystery. On October 23, CMS announced further guidance regarding RAPS and EDS Submissions.

There were three key elements:

1). The addition of diagnoses submitted after the risk adjustment deadline for payment year

2). The submission of HIPPS Codes for CAH’s

3). The use of default NPIs for atypical providers.

Gorman Health Group (GHG) continues to stress the importance of accurate and timely submission of RAPS and EDS files to CMS. This memo clearly supports our rationale behind this emphasis, and it takes it one step further. Your organization not only needs controls on the front end, it needs quality oversight and standard operating procedures in place to manage the file return elements from CMS.

CMS states that it will not incorporate into the risk score for a payment year additional diagnoses submitted after the risk adjustment deadline. Specifically, after the final risk adjustment submission deadline for a payment year, only diagnoses deletes will be included in a rerun of risk scores for the payment year. Knowing this, there is no time like the present to reevaluate your RAPS and EDS processes. Our new capability will help your plan do this while calculating and defining its current level of risk.

This is a critical time and an imperfect process for health plans and risk baring provider groups, GHG is excited to introduce our new RAPS/EDS Variation Analysis capabilities. Our team of operations and data experts will assess your current processes and data, identifying gaps and discrepancies that need to be addressed in order to ensure compliance and secure accurate payment from CMS through Risk Adjustment operations.

Clients will receive the following critical items upon completion of the analysis:

• Operational Assessment Report – Outline of the processes that the health plan currently has in place for RAPS/EDS file submissions, returns and error resolution, providing areas of opportunity for improvement.
• Variation Analysis Review – Review of findings, outlining instances for potential inaccuracies and risks associated with the health plans current methodology and processes applied to the internal variation analysis.
• Discrepancy Reports – Identifies opportunities to improve completeness and accuracy of each submission to CMS.
• Encounter File Member Analysis – Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the RAPS file member analysis.
• RAPS File Member Analysis – Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the encounter file member analysis.

With this information, a health plan can feel confident that they fully understand the revenue and operational impact of this transition and are able to put processes in place to ensure that there is no loss of revenue or instances of data inequities when transitioning to the Encounter file format. 

For more information on our approach and the results, please contact me directly at dweinrieb@ghgadvisors.com.

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