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Siva Tunga, Sr. Director, Product Management, EdifecsAbhimanyu Dua, Sr. Manager, Advisory Services, Edifecs

How to Ensure RAPS & EDPS Submissions Equal Revenue Success

H E A LT H C A R E PA R T N E R S H I P S :

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Agenda 1. Who is Edifecs?

2. RAPS to EDPS challenges

3. Say no to the “legacy” approach or else….

4. RAPS to EDPS use case

5. Your success checklist & getting started

6. Wrap up & questions

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Innovator in Healthcare IT

“Customer first innovation model, proven by 20 years of reinvesting into new solutions to meet the demands of the radical

transformation impacting healthcare”

Serving more than 215 million lives through our 350+ customers

Worldwide745+ Employees

LeadersIn Trading and Compliance

MultipleFederal Agencies incl. CMS

Top Health Plans Care Providers

100

Blue Plans Medicaid Programs

27/52

Encounter Management Solution Profile

AccuracyAchieved 99.99 % submission compliance and risk score revenue accuracy for our customers

Substantial Submission Footprint300M encounter submissions annually across Medicare Advantage, managed Medicaid & the Marketplace

Market LeaderOverall, 15% of encounters submitted to CMS are generated by our system

Submission TypesSingle platform to support federal, state, APD and custom encounter submissions

Serving more than 8 Million lives through our customers

8/9 25/36

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RAPS to EDPS challenges

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What You Don’t Know Can Hurt You!

HCC Coding

Submission Quality

Submission Timeliness

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RAPS to EDPS:What You’re Up Against

Risk score impacts not integrated with

exception prioritization, chart

review and tracking

Different formats and rules for data

submissions in RAPS vs. EDPS

Inconsistent inbound data

sources (vendor data /

supplemental data)

Varying validations (EDPS)

/ filter logic (RAPS)

Discrepancy identification and resolution during

response reconciliation

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Cost of the status quo

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The cost of the status quo

Transition Timeline

* Projections where risk score models also will change leveraging ICD-10 data

2016 risk

score

2017 risk

score

2018 risk

score

2019* risk

score

2020 risk

score

RAPS – 90%

EDPS – 10%

RAPS – 75% RAPS – 50% RAPS – 25% RAPS – 0%

EDPS – 25% EDPS – 50% EDPS – 75% EDPS – 100%

~ $200K-$250K/year additional FTE cost managing the reconciliation and tracking submissions with

legacy systems

Cost of chart reviews, additional diagnosis codes reporting will cost around $50-$60 per claim to

reconcile RAPS and EDPS

1 base point variation ~$100K in revenue impact with missing risk scores between RAPS and EDPS

2 % of diagnosis codes have potential variations in risk scores in ICD-10 due to unspecified code usages, granularity and combination codes

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Use Case

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Use Case : Medicare Advantage expansion

Business Drivers

Regulatory submission compliance

Risk adjustment and revenue cycle visibility

Prospective and retrospective suspecting

Challenges

• Identify variations in RAPS and EDPS Submissions

• Reconciliation of RAPS and EDPS

• Ensuring compliance

Requirements

• Consolidate encounter book of record across multiple LoBs

• Prioritize encounter submission workflow based on RA impacts

• Maintain and track changing state and CMS guidelines

• Improve risk score and payment visibility through RAPS/EDPS encounter submission reconciliation

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Identifying variations in RAPS & EDPS submissions

Perform baseline analyses using historical data to analyze impacts

1 Baseline analysis of historical risk scores submitted through RAPS and compare with submitted EDPS data

2 Determine gaps in risk scores that drive the list of variations and scenarios

3Identify conditions causing filtering logic variations – type of bill, diagnosis codes and POS combinations, chart review submission

4 Implement a data extraction and submission process to reduce variations

5Periodic reporting to analyze member level RAPS and EDPS diagnosis codes submitted and reconcile the gaps

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Ensure compliance for encounter submission

Ensure all claims are accounted for submission from both RAPS and EDPS

Identify missing RAPS and EDPS

data

• Vendor data• Capitated claims

Reconcile filtering logic

• Incorrectly filtered claims (behavioral, mental health, DME, skilled nursing)

Identify chart review data submissions

• For RAPS - Using direct entry into CMS

• Ensure chart review deletes and replacements

Enable exception prioritization and

submission

• Build process to reconcile exceptions

• Track submissions in both formats

• Prioritize exceptions based on HCC impacts

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Reconciling RAPS and EDPS submissions

Encounter /Claim System

An application/process to reconcile/Link RAPS and EPDS submissions at claim and member level

Build member level dashboards to show RAPS and EDPS diagnosis codes and statuses

Identify members with risk score diagnosis variations

Categorize and analyze missing diagnosis codes

Prioritize claims for corrections, updates based on HCC risk score impacts – high risk score

Reconcile diagnosis codes with MAO-004 Reports

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RAPS/EDPS success checklist

2017 Payment Year & Beyond Build repetitive process to

perform periodic reconciliation

Run through pre-edits / filter logic prior to submissions

Generate single view of RAPS and EDPS risk adjusted diagnosis

2016 Payment Year Run process to compare

RAPS reply to EDPS responses

Compare risk adjusting diagnosis codes

Discrepancy identification and resolution

Engage with external vendor for reconciliation

Plans would need to reassess capabilities to perform effective RAPS /EDPS reconciliation and build capability to have a single view of risk impacts and submissions

Coming Soon

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