As CMS ties payments to EDPS results, Health Plans turn to Dynamic Healthcare Systems for Risk Adjustment Calculations
Irvine, CA. – June 14, 2016 — Medicare Advantage Organizations (MAO) are scrambling after the recent announcement by Centers for Medicare and Medicaid Services (CMS) regarding the Risk Adjustment Processing System (RAPS) to Encounter Data Processing System (EDPS) transition. Beginning with 2015 Dates of Service (DOS), 10% of reimbursement dollars are tied to EDPS submittals as well as RAPS data and for 2016 DOS that percentage shoots up to 25%. Time is of the essence for MAOs to prepare for the complete RAPS to EDPS migration. Dynamic Healthcare Systems, a provider of enterprise-wide solutions for government-regulated health plans, is fully ready to support the CMS MAO-004 report and support plans during the migration period. The MAO-004 Report data represents a major change to the filtering method used to support risk adjustment calculations and will significantly affect the payments MAOs receive.
Kathy Feeny, President and CEO of Dynamic Healthcare Systems, shared “In 2015, Dynamic processed millions of encounter transactions. Our 98%+ acceptance rate (MAO-002) assures MAOs that the Dynamic solution is assessing the maximum number of encounters 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 Encounter Data System (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.”
Dynamic’s end-to-end platform includes solutions to submit both RAPS data and EDS encounters to CMS through each phase of the RAPS to EDPS transition. Previously, MAOs submitted risk adjustment eligible diagnoses in a minimum 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 risk scores from both systems for PY 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. CMS recently announced the weighted blend for PY 2017 (2016 DOS) will be RAPS 75% and EDS at 25%. 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 and innovative solutions to companies serving the government-regulated healthcare population. For more information, visit www.dynamichealthsys.com or call 949.333.4565.