If you haven’t already, commit this date to your memory: January 31, 2017. It’s the final deadline for Medicare Advantage Organizations (MAO) to submit RAPS and EDPS data to CMS for the 2016 payment year (so, the final reconciliation of 2015 dates of service). The deadline is the last chance to submit any codes for conditions that were documented by the physician but were coded incorrectly or not coded at all. CMS uses the submitted claims and encounters to identify HCCs and set risk scores, which in turn determine a Plan’s reimbursement rate. Submitting incorrect or incomplete data could result in CMS assigning risk scores that don’t accurately reflect the Plan member’s true health status, leading Plans to get either an overpayment (which they have to pay back) or, worse, an underpayment.
What This Means for Providers
A Plan’s failure to deliver correct coding can in turn cause their provider’s payments to be delayed, denied, or limited. CMS has made it very clear that once the deadline has passed, they will not incorporate any more diagnoses into the risk score calculation. Whether you’re using certified coders or are a physician coding at the point of care, understanding your patient population and their true health status is critical; failing to identify and correctly code patient diagnoses creates significant downside risk since your reimbursement rate will not match your true cost of care. It’s fair to say that payment accuracy (from CMS and to providers) is directly affected by the quality and accuracy of your coding.
With the submission deadline just a few months away, providers can’t start preparing soon enough. Here are three things that you can do right now to help pave the way for a smooth RAPS/EDPS submission, putting you in the best position to receive accurate reimbursements:
In some ways, the old adage “garbage in, garbage out” applies here. Medicare Advantage providers have a huge stake, both in terms of payment accuracy and care quality, in taking the steps needed to ensure the data submitted to CMS is correct. Coding InSight by Talix can take a lot of the burden, inaccuracy and inefficiency out of the equation, all while enabling better quality of care. Contact us and we’d be happy to show you how.