With up to half of a health plan’s revenue determined by the health status of its membership, accurate data submissions play a key role in both regulatory compliance and financial performance. A misstep in your documentation can make or break you, especially as it pertains to risk adjustment data compliance.
Whether you are managing Medicare Advantage (MA) encounter data or the Commercial Affordable Care Act (ACA) risk adjustment data submissions for payment reconciliation, with different requirements for each line of business, the submissions process is complicated and complex – and it’s not just the separate requirements that can cause hiccups. Medicare data files must be submitted through the Risk Adjustment Processing System (RAPS) and Encounter Data Processing System (EDPS) – currently transitioning to 100% EDPS in the future – while ACA data is submitted through the EDGE Server. The two separate systems for risk adjustment payments and capitation add a layer of complexity to the balancing act.
Meanwhile, ongoing revisions that are made to CMS compliance regulations call for health plans to be agile, while also ensuring they are submitting complete and accurate transactions within the mandated timelines. To put it simply, health plans must keep up and comply with deadlines or risk being penalized – a costly penalty, but one that can be avoided.
In a rapidly changing market, one key to risk adjustment success for any health plan is the ongoing assessment of process improvement opportunities. This is particularly true regarding claims submissions for risk adjustment, given that encounter data has become more salient. Let’s talk about three proven practices that will best serve your organization’s efforts to collect and report quality data, enabling efficient CMS risk adjustment submissions.
1. Ensuring Complete Submissions Data
Despite each line of business having its own set of requirements, regulatory bodies use historical encounter data for setting and adjusting capitation payment rates for all managed care organizations (MCO). CMS needs complete, detailed encounter data for a full picture of how care was provided as well as how much care was provided – increasing its strength as a data source (i.e., inpatient stays, hospitalizations and special needs facility information, etc.). Essentially, missing or incomplete data impacts an MCO’s future payments, so it’s in everyone’s best interest to submit complete and timely data to avoid inaccurate reimbursement. But what constitutes complete risk adjustment data anyway? For complete Medicare submissions, medical records should be supported by conditions that have been coded and clinically validated on medical claims or encounters and all co-existing conditions that impact member care should be coded to ensure chart reviews are present. The best way to achieve complete data for ACA is through physician documentation, pharmacy and enrollment data.
2. Increasing Accuracy and Efficiency
Encounter errors carry financial impact for Medicare, and enrollment and pharmacy errors carry financial impact for ACA. Identifying those errors before submitting data files to CMS will prevent revenue loss, but it requires a strategic approach. Addressing errors and ensuring accurate data submissions improves acceptance rates and drives risk score accuracy. Improving the accuracy of your submissions and increasing acceptance rates translates to greater compliance rates for 1. improved financial performance 2. the elimination of duplicative processes, and 3. more rapid achievement of financial transparency. This is even more reason to make a concerted effort to evaluate claims for accuracy based on CMS guidance prior to submission.
But, what is deemed “accurate” data? Data is considered accurate when submitted diagnosis codes are obtained through a face-to-face doctor’s visit and documented correctly in the medical record. There are several ways to ensure the data you are submitting is accurate:
3. Submitting On-time
Health plans of all sizes and across all locations are challenged by the balancing act of providing quality healthcare to members while monitoring and adhering to CMS regulations. A significant element of health plan data management and oversight includes staying ahead of industry deadlines. Ultimately, for every health plan and business line, adherence to CMS risk adjustment deadlines is required to circumvent possible penalties. Data submission deadlines and applicable open dates of service (DOS) vary between MA and ACA. There are three annual submission deadlines for MA risk adjustment, commonly referred to as “sweep dates” or “CMS risk adjustment sweeps,” using the RAPS/EDPS system. ACA has just one final deadline annually and four interim deadlines for quarterly data submission to adhere to that are submitted through EDGE Servers. Having a combination of effective procedures to manage deadlines along with expertise is key to managing mandated timelines.
The bottom line for government-supported health plans is course correction. As part of healthcare risk adjustment, there needs to be visibility into the data for reconciliation and the ability to quickly identify the outliers. The last thing an MA or ACA health plan wants to do is miss out on significant reimbursement for member management due to inadequate reporting. Having the necessary processes and resources in place to properly manage your risk adjustment data submissions – from data integration to acceptance and reconciliation to actuarial forecasting – will reduce error correction work and ensure you are accurately compensated, allowing you to provide high-quality care for your members.