Risk Adjustment

CMS Again Extends 2015 DOS Deadline for EDPS Submissions

In a memo released Friday regarding risk adjustment data deadlines, the Centers for Medicare & Medicaid Services (CMS) extended the Final 2016 (2015 DOS) for EDPS submissions to April 2, 2018. This is the second deadline extension; the original deadline, which had initially been Jan. 31, 2017, was moved to May 1, 2017, reportedly due to the need to fix internal CMS system errors.

Though no reason was given for the latest extension, an opportunity now exists for health plans to revisit their 2015 DOS EDPS submissions. Additionally, health plans should be ready for other deadline shifts, as well. While obviously not official, health plans should not be surprised if CMS extends the Jan. 31, 2018, deadline for EDPS data for 2016 DOS. (We do not foresee CMS extending the Jan. 31, 2018, RAPS data submission deadline for the same dates of service.)

An Opportunity for Payers

With the announcement’s definite implications for 2015 DOS EDPS submissions, and potential implications for the 2016 DOS EDPS submission deadline, health plans absolutely must continue focusing on submitting. However, they also should make sure their error management system is effective.

No matter what system a health plan uses, whether home-grown or a vendor’s, the number one consideration when it comes to encounter data is workflow. To that end, an automated process is a must-have for an efficient risk adjustment program. Strategically, automation is the best way to create a system that has the following key features.

Error Identification
Finding errors in data is a standard feature of most risk adjustment software. But a list of errors, by itself, is not enough. Good error management means making sense of the data by being able to sort and categorize it based on multiple criteria, including the top 5 Encounter data errors in 999, 277 and MAO-02.

Financial Projections
Being able to see the financial impact of every error enables plans to determine the best order to resolve them. A strong risk adjustment program will highlight errors with the greatest HCC impact and provide accurate financial projections for reimbursement based on the particular errors and/or groups of errors that are resolved.

Error Queuing
Once the starting point is decided, a strong risk adjustment program will easily create workflows that automatically queue errors for resolution within the user interface. Another feature to consider is the ability to queue the fixed data for submission or resubmission.

Clearly, the RAPS-EDPS transition is still experiencing challenges. For health plans, this is a definite opportunity to scrutinize their current error management system. Because it’s not just about detecting errors quickly, it’s more important for health plans to know what the errors mean to the bottom line. For payers still struggling with their EDPS workflows and systems, Friday’s announcement may be a just-in-time window of opportunity.


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