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CMS Begins to Move Again on Encounter Data Transition

CMS Begins To Move Again On Encounter Data Transition

There has been notable flux in the Centers for Medicare and Medicaid Services’ (CMS) effort to retire the old Risk Adjustment Payment System (RAPS) of encounter submission in favor of the HIPAA 837-based Encounter Data Processing System (EDPS). After setting a definitive sunset for RAPS in 2020 a few years ago, CMS suspended the phaseout due to some gaps on its end (numerous report issues) but especially due to the likely major revenue reduction plans would see because most had not planned accordingly. In fact, in 2018, it took a step backward from the 2017 75% RAPS-25% EDPS mix to 85% RAPS/15% EDPS in the current year. But when committed to something, CMS also recalibrates and plods on. Transition

Now there is movement:

  • For 2019, the blend will return to 75% RAPS and 25% EDPS. While a new phaseout calendar has not been set, it is likely that CMS will aim for a complete phaseout of RAPS in favor of EDPS perhaps as early as 2022. The 75-25 is a little more complicated than straight percentages.
    • 75% is RAPS and FFS only, using the old CMS-HCC model
    • 25% is EDPS supplemented by RAPS inpatient scores and FFS, using the new CMS-HCC model
  • In June of 2017, it issued a tremendous and thorough best-practice memo for encounter collections using the new system. See our blog on this topic here.
  • On August 20, 2018, a little over a year from its best practice pronouncement, CMS issued a memo on monitoring and compliance of encounter data. These performance metrics will be used on a go-forward basis to assess plan encounter performance as well as levy penalties and sanctions. The metrics will be determined at the contract level. The table below shows the final seven metrics, two original and five new, all based on the concept of operationalization and completeness. The third goal of accuracy is not yet measured. It is important to note that these metrics are based on thresholds to identify performance issues that are substantially below reasonable expectations for submissions. Interestingly, in at least two important measures, 5 to 8 percent of plan contracts miss the mark even with fairly liberal metrics. In the future, the thresholds will likely get tougher. Plans need to examine the HPMS memo (found here) and assess how they fare.image
  • In an August 28, 2018 HPMS memo found here, another shot came across the bow from CMS. In the memo, CMS clarified its April 9, 2018 memo (found here) that a Chart Review Record (CRR) submission alone is not a substitute for an EDPS submission. CMS indicated in the August 28, 2018 memo that:
    • A CRR should only be submitted for the purpose of modifying risk adjustment diagnosis data for a Medicare Advantage enrollee.
    • Default HCPCS codes must be submitted consistent with the CMS filtering logic: diagnoses that are disallowed for risk adjustment should not be submitted with default HCPCS codes that would cause the diagnoses to be allowed for risk adjusted payment. Similarly, other data elements, such as the dates of service, should preserve the integrity of the associated encounter and medical record from which the CRR was created.
    • Items or services provided to an enrollee under the plan must be reported on an Encounter Data Record (EDR – another terminology for an EDPS or 837 submission). A CRR should not be the only record with information about a healthcare item or service provided to a plan enrollee.

In essence, it is saying that while unlinked CRRs can still be submitted, they should tie to an underlying EDR. If there was any doubt about CMS’ position, it added: “Specifically, MAOs and other submitting organizations are required to ‘submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner’ (42 CFR 422.310(b)). CMS has provided guidance that Encounter Data Records (EDRs) are the means for meeting this requirement.” CMS notes that not every service can be submitted via an EDPS submission. It said it will dialogue with plans on this but essentially punted a decision here to another day as to not water down the core message related to the purpose of the CRR.

The significance: CMS wants to establish strong integrity to the EDPS submission process to accomplish numerous goals centered on rate-setting, quality, payment integrity and more. The current RAPS process is fairly simple and its supplemental submissions liberal. Chart reviews and supplemental submissions leading to more revenue are easily accomplished. RAPS submissions based on an actual claim/encounter or subsequent chart review can be made without regard to another. There was no effort to tie chart reviews to claim/encounter submissions. EDPS is a different story – a complex process of submission, greater chance of rejects, and much tougher remediation. CRRs here will derive less revenue given that a CRR will need to be tied to a successful encounter submission and the integrity of the submission kept intact.

So, while chart reviews won’t go away, it will be incumbent on plans to ensure that its 837 process submissions are reliable and predictable, and that processes are established to ensure robust and accurate submission of all encounters and claims from providers upfront. The old world is going away!

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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