What is Changing?
Currently, the calculation for setting capitation rates used for Medicare Advantage is based on cost (claims) data collected from fee-for-service providers. That is about to change. CMS will soon be setting the rates on the fee-for-service equivalent pricing using “encounter data” submitted by Medicare Advantage Plans. While CMS has been collecting Medicare Advantage encounters for the past 2 years, as of this time, no official date has been announced to begin calibrating rates using Medicare Advantage data.
What is the Difference Between RAPS and EDPS?
- RAPS data is edited for enrollment, duplicates, and validity of diagnosis codes
- EDPS data is edited for enrollment, duplicates, diagnosis codes, CPT codes as well as coverage and clinical consistencies. EDPS data must also pass CCI edits similar to those used with FFS claims
- RAPS requires HICN, DOB (optional), diagnosis codes, date of service, and provider type
- EDPS requirements are more comprehensive and complicated. All data elements from the ANSI 837 v5010 claim format are required.
Tips for Health Plans from CMS:
The March 2014 Encounter Data Newsletter included the following tips:
- Regularly Reconcile Reports – Reconcile MAO-002 Encounter Data Processing Status Report often.
- Join the ListServ – Stay up to date on the latest encounter data news by subscribing to updates from the CSSC Operations website and the Technical Assistance Registration Service Center (TARSC) website.
- Continue to Submit RAPS in 2014 – RAPS will continue to run parallel to the EDPS in 2014.
Tips for Providers:
- Establish a protocol of checks and balances in documentation to ensure that all services are documented correctly. Be sure you have an in-depth knowledge of FFS billing protocols and the importance of complete diagnosis as well as CPT coding and documentation.
- Activate software functionality that allows billers to generate reports on claims rejections on a timely and regular basis. Be sure to track any rejections by reason codes so ongoing problems can be corrected and re-submitted quickly, to recoup dollars that may otherwise be lost.
- Audit a sampling of charts quarterly to determine if the documentation protocols for correct coding are being applied appropriately.
The shift from RAPS to EDPS represents a significant change in how capitation rates are set for Medicare Advantage. Health plans and providers must adapt to these new data requirements and editing processes. Regular reconciliation and staying informed about encounter data updates are essential for health plans, while providers should focus on comprehensive documentation and the ability to track and correct rejections effectively. This transition requires diligence and collaboration between all parties involved to ensure a smooth adjustment.