Medicare Advantage Providers, Payers Should Care About the RAPS Deadline. Here’s Why

Dean Stephens
August 3, 2016

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:

  1. Understand RAPS v. EDPS. 2016 is the first year that CMS is using a blend of both data sets for risk score calculations. Because EDPS data is much more complex and includes thousands more codes than RAPS, it’s easier to make mistakes that lead to rejections. Decrease the chance of costly errors by making sure you’re up-to-date on the new coding guidelines. For the 2016 payment year, the portion of a risk score that is determined by EDPS is 10 percent, but that goes up to 25 percent for 2017 and increases from there until it reaches 100 percent in 2020, so the stakes are only getting higher from here.

  2. Get it right the first time. Audits are usually done retrospectively, and payer reports are typically 90 days old, so any gaps that are found later in the year can contribute to the dreaded “year-end rush” to schedule and see patients to confirm un-coded diagnoses. Investing now in an analytics solution that can do automated retrospective reviews as well as enable more accurate and thorough prospective coding according to true illness burden – in real time and at the point of care – can have a significant effect on the quality and completeness of the data you submit, as well as on the quality of care you’re able to provide to patients.

  3. Audit yourself. Run regular reports on claims rejections so you can track where and why they’re happening, and correct the data well before the deadline. Taking some time now to ensure you’re correcting data on a regular basis can save you headaches down the road.

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.

Dean Stephens is the CEO of Talix.
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