It’s Game Time – Medicare Advantage Plans Need to Get Serious About CMS Rule Changes

By Abhinav Aggarwal, Sr. Director, Encounter Submission and Risk Adjustment Solutions, Edifecs
Twitter: @edifecs

Fall isn’t just about football. There is another game heating up this season, and the costs of losing could be devastating. Just like football, the Medicare Advantage market is highly competitive, with each player fighting to score big. And why not? It’s a great time to get into Medicare Advantage since it’s the one line of business that continues to consistently grow, while the future of the Affordable Care Act is uncertain. However, if payers don’t get off the bench and adjust their game plans to meet CMS’ proposed encounter management policies quickly – their season may come to a close sooner than they planned.

Players are Adjusting to New Rules
Just because the industry is seeing great growth, does not mean all plans will be successful and profitable. Medicare Advantage comes with its own set of challenges and requires deep expertise in many different areas to ensure continued success – especially when it comes to data.

Today, health plans must send two file types (RAPS and EDPS) concurrently for payment reimbursements. But soon, the rules will change and plans will need to adjust to CMS’ ruling that over the next two years, one of the file types (RAPS) will be decommissioned and the other (EDPS) will be the sole source used for payment reimbursements. And the expectation is that there will be a 50/50 split of RAPS/EDPS for 2020.

This makes many health plans nervous since they are used to the old rules, but CMS is holding firm with sun-setting their existing RAPS processing and moving to using only encounter data to calculate member risk scores and payments.

The Cost of Losing
This means health plans need to double down on their efforts to ensure their encounter data processing is fully functioning. Revenue integrity will rely only on encounter data, and health plans must send the data in a timely manner, and make sure encounter data is complete, accurate, and can be traced back to patients’ original medical chart documentation.

CMS found that $16 billion risk adjusted payments based on RAPS data submitted was not supported by medical records. The move to encounter data will put the ownership of calculating risk scores and payments on CMS, but the health plans will still need to ensure the encounters tie back to the source with 100% accuracy, otherwise they face costly penalties.

Early Round Predictions
While the costs of losing can be hard, there are a few keys to a winning game plan. First, interoperability between payers and providers will be crucial to accurately track and report encounters. Second, clinical data will need to start flowing more consistently from providers to payers. Finally, health plans will need to start confirming inbound claims to clinical data at the gateway in a more real-time fashion.

While the season is just getting started, the time is now for health plans to address their encounter submission game plan.