As you know, CMS now uses a combination of RAPS (Risk Adjustment Processing System) data and encounter data submitted thru EDPS (Encounter Data Processing System) as inputs into the payment system for projecting RAFs (Risk Adjustment Factors), which is a key input to payment model for MAPD (Medicare Advantage Prescription Drug) health plans. CMS requires that all encounter data be submitted by MAPD health plans, including services not covered by CMS in Fee-For-Service (FFS) Medicare.
Due to the growth of payment strategies such as capitation in MAPD, providers are no longer financially incentivized to provide complete data as they were in the traditional claims billing process. This has been a widely identified trend in MAPD professional data, but also occurs in the inpatient setting which often contains more robust information then other places of service. Missing encounter data and the growth of the gap in these data (between MAPD and FFS) has a number of important ramifications for MAPD:
- · It causes inaccuracies in payment because treated conditions are not reported and therefore not loaded into the payment model
- · It suggests a distorted picture of members’ true disease burden as being lower than the actual
- · It suggests incorrectly to CMS that MAPD members are receiving fewer services than beneficiaries in traditional Medicare (FFS)
Some possible drivers for this under-reporting are:
- · Failure to submit data from sub-capitated providers, including hospitals
- · The purposeful filtering of encounter data submitted to the plan with the goal of providing only incremental HCC model data
- · Downstream data that medical groups processes as claims are not always extracted and reported. This is especially true when the groups’ encounter data and claims data are on different platforms.
- · Selective reporting from providers of only risk adjustable diagnoses in MAPD and only providing a single E&M procedure code so that the encounter will process
- · Submitting reporting from providers of only diagnoses “linked” to a procedure code for traditional Medicare claims or only the minimum needed for the claim to process
While there are no mechanisms in traditional Medicare at present to submit additional diagnosis data (maximums are currently <=8 diagnoses for professional, <=25 diagnoses for institutional), it’s important to submit all documented diagnoses and procedures for both programs. In traditional Medicare where there are more diagnoses then 8, we would suggest that the provider or biller first choose linked diagnoses followed by the diagnoses that most accurately reflect the need for the visit and evaluations conducted at that service. Similarly, reporting all CPT/HCPCS codes is important since it is the only way that CMS can gain an accurate picture of procedures performed with the goal of trying to understand and compare value between the programs.
At present we believe that there are a number of systematic biases that are impacting the accuracy of the view CMS has on the health status of the entire Medicare population, biasing towards fewer CPT/HCPCS for MAPD and fewer ICD codes for traditional FFS.
Remember, SCAN’s Encounter and Risk Adjustment provider team is here to assist you. Please reach out to Michelle Nguyen at MNguyen3@scanhealthplan.com for assistance.