End-to-End Medicare Advantage Enterprise Platform Upgraded to Conform with Major CMS Risk Adjustment Changes
Irvine, CA – February 23, 2016 – Dynamic Healthcare Systems, a provider of enterprise technology solutions for government-regulated health plans today announced an upgrade of their Encounter Data Processing System (EDPS) to support the Centers for Medicare and Medicaid Services (CMS) Medicare Advantage Organization MAO-004 report file. The MAO-004 report file data is a significant change to the filtering method used to support risk adjustment calculations and will affect the payments MAOs receive.
According to Kathy Feeny, President and CEO of Dynamic Healthcare Systems, “In 2015, our EDPS processed millions of encounter transactions. Our 98%+ acceptance rate (MAO-002) assures MAOs that the maximum number of encounters are assessed for risk adjustment. Our EDPS system will now import and process the new MAO-004 report file as well as provide pre-“MAO-004” prospective analytics. Our Hierarchical Condition Category (HCC) Analytics solution uses the risk adjustment indicator provided in the CMS EDS filtering logic as well as the MAO-004 when calculating expected Risk Adjustment Factor (RAF) scores and identifying suspects. The risk adjustment indicator is a crucial element for accurately reflecting risk adjustment factors used by CMS.”
Previously, MAOs used their own filtering logic and submitted adjustment-eligible diagnoses in a very small data set consisting of 7 fields to the Risk Adjustment Processing System (RAPS). Now, MAOs must also submit encounter records with over 1,700 data elements, including all diagnoses, to the Encounter Data System (EDS). CMS, rather than the MAO, filters diagnoses submitted to the EDS and identifies those that are eligible for risk adjustment. CMS will equally use diagnoses from both systems for 2015 payment (2014 DOS). Beginning with PY 2016 (2015 DOS), CMS will use a weighted blend (RAPS 90%: EDS 10%) as a basis for risk score calculations used for MAO payments.
Dynamic’s end-to-end platform includes solutions to submit both RAPS data and EDS encounters to CMS. Additionally, Dynamic’s HCC Analytics solution examines all source data to calculate expected Risk Scores and identify member and provider suspects as well as encounters that are likely to risk adjust, but have not passed through all of the CMS validations.
About Dynamic Healthcare Systems
Dynamic Healthcare Systems, Inc. delivers comprehensive enterprise software solutions and services for health plans with Medicare Advantage, Medicaid, and Marketplace lines of business striving to succeed amid new and evolving regulatory requirements. Headquartered in Irvine, California, the company brings world-class innovations to companies serving the government-regulated healthcare population. For more information visit dynamichealthsys.com or call 949.333.4565.