January 24 2017 | 0 Comments | 2566 reads Average Rating: 4

Procrastinate No More: The Time to Embrace EDPS is Now

by SCIO Health Analytics in Risk Adjustment

Healthcare organizations that participate in the Medicare Advantage program need to start paying closer attention to the need to collect more detailed encounter data – or they will soon feel much more than just a little financial pinch.

The monthly payment that a Medicare Advantage Organization (MAO) receives from the Centers for Medicare & Medicaid Services (CMS) will increasingly hinge on more complex encounter data as the transition from the Risk Adjustment Process System (RAPS) to the newer Encounter Data Processing System (EDPS) continues to unfold. In fact, the percent of a MAO’s risk score that is determined according to data from EDPS will rise from 10 percent for payment year 2016 (for 2015 dates of service) to 25 percent for payment year 2017 (for 2016 dates of service) – and will eventually hit 100 percent in payment year 2020 (for 2019 dates of service), when RAPS is completely eliminated.

As such, the need for health plans and provider organizations that are participating in Medicare Advantage to get out of their comfort zones and move to the EDPS system is growing more urgent. As the new system becomes the predominant one, healthcare organizations can potentially experience crippling financial effects if they have not successfully transitioned to the EDPS system.

As such, these organizations need to take the following steps – sooner rather than later:

1. Look for discrepancies between the two data sources and identify where EDPS data is lacking.

2. In cases where EDPS data is missing, organizations need to analyze the data flow from provider to health plan to government. By doing so, organizations could potentially discover that EDI vendors are employing data edits that are inadvertently kicking some diagnoses out of the EDPS system; random diagnoses are not being captured in EDPS; or specific billing systems might be missing certain diagnoses.

3. Ensure that data submitted in an alternate format is captured as a claim. For example, it’s important to consistently capture data that is submitted from a chart review.

4. Understand what went wrong. If data is rejected from the EDPS system, it is important to identify exactly why, make a needed correction and resubmit.

To successfully work through this checklist, however, is a formidable task that requires data analytics. SCIO offers sophisticated data analysis that makes it easy to pinpoint and correct discrepancies; the reporting that makes it possible to understand the particulars of the Medicare Advantage program; and the support and training that ensures that organizations will be successful in Medicare Advantage programs.

Leveraging such an analytics program is a key component associated with the successful transition to EDPS.

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