As the Centers for Medicare & Medicaid Services (CMS) continues the transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS) for calculating Medicare Advantage risk scores, payer organizations should have a plan in place to minimize system errors under the new model. Success during the transition lies in collaboration among departments, as well as understanding the different data processing models in both RAPS and EDS.

Encourage Inter-Department Collaboration

Payer organizations that aren’t prepared for the RAPS to EDS transition are likely to see a negative effect on their revenue stream. However, many errors can be negated by encouraging their various departments to collaborate and communicate frequently through regular meetings, training, or other channels.

Creating a relationship between the departments involved in the process — like the claims, IT, and operations departments — eliminates silos that cause unnecessary obstacles. For example, a health plan may need a more structured system for streamlining communication. During the transition process, the claims, enrollment, and provider relations departments will have to work together to figure out the enrollment status of a member or reach out to providers that are responsible for a high number of errors.

The providers driving a large number of errors can be highlighted by encounter data software or an internal review. Once providers are identified, reaching out to those providers with an automated campaign can help gather necessary provider attestation for edited and corrected codes. This collaboration between internal departments and physicians can help reduce redundancy across the organization, improve coding accuracy, highlight opportunities for provider education, and make financial forecasts more accurate.

Be Aware of Data Differences

EDS submissions require 150 fields of data while RAPS requires less than 10, which means most health plans will see more errors on the EDS side. Organizations need to take a deep dive into those EDS errors and ensure that claims are passing through both systems. For example, if payers have different logic for the data that gets submitted into RAPS versus EDS, this process can become complicated. It requires organizations to pass RAPS data through the same model as CMS EDS data, as well as run the claims analysis through the EDS filtering logic to highlight which passing codes would impact dollar amounts. Payer organizations should be aware of the differences in submission logic and take proactive steps to minimize disparities before submission.

The transition to EDS can seem overwhelming due, in part, to the larger number of areas to troubleshoot. If an EDS data submission is returning a significant number of errors, consider generalizing the errors. See what the top errors are on the EDS side — they could be a system error that can be easily fixed. System errors could be caused by a duplicate service line or invalid type of bill code for a UB claim, for example. If not, the department in charge of creating the 837 files may have to create a default logic to manage errors.

Implement Review Processes

Procedure and bill type codes can cause confusion in the transition from RAPS to EDS. They’re not required in RAPS but are generally necessary in EDS, depending on what type of claims you’re submitting. The department responsible for the risk calculation may encounter a bill code that’s documented mistakenly or procedure codes duplicated on multiple lines of service. Fortunately, these mistakes can be caught before the 837 file is created, enabling organizations to fix such errors at the outset. Once these errors are corrected, it is possible to filter down to some other areas that may be causing a negative financial impact on the EDS side.

Even if the claims department is comfortable with a front-end system with RAPS, they may not be experienced in working with procedure codes since these weren’t required before EDS. The department would have to ensure codes in EDS are valid and contain the correct information. For instance, some insurance companies utilize internal procedure codes on claims to enable their system to recognize them. It’s essential to make sure those codes don’t get added when the 837 file is being submitted.

Though software can catch many errors and batch fixes can be applied, human review in this process is critical. The more familiar organizations can be with the data, the claims systems, and the process used to convert claims to an 837 file, the better. Such insight allows plans to more easily determine where errors might be originating from and how to fix them.

Tackle the Transition

A detailed communication plan and awareness of data processing models and coding differences are essential in ensuring that organizations transition successfully to the new model. However, not planning ahead and educating employees on the transition could lead to fewer risk scores submitted, resulting in reduced payment for organizations.

Supplementing in-house resources with encounter data software can help make the transition to the new model smoother. EDS software can help streamline the reconciliation of RAPS with EDS by identifying inaccuracies and errors in both models to ensure acceptance and proper calculation of risk scores and payment by CMS.

For overburdened payers and providers, Episource helps close gaps in healthcare by marrying expert guidance with an end-to-end risk adjustment platform. Learn more about our solutions at Episource.com.