UPCOMING EVENT: Meet Episource and Catch Our Presentation at the RISE Risk Adjustment Forum, May 20-22 in New Orleans.  Click to Lean More!

Advance Possibility

And That’s a RAPS!

person touching screen with fingertips
Meleah Bridgeford
Sr. Director of Risk Adjustment Analytics
September 17, 2020

On Monday, September 14, 2020, the Centers for Medicare & Medicaid Services (CMS) released their annual Advance Notice three months earlier than what we have come to expect. This is a move that, even though it was offered as a possibility, is one more unprecedented occurrence for 2020.

“All stakeholders are grappling with additional uncertainties created by the COVID-19 pandemic.”

CMS indicated that the early release was to offer more certainty to Medicare Advantage Organizations (MAOs) during this “unusual time.” The extra few months are meant to give health plans more breathing room to respond to the rate announcement and prepare bids before June. Similarly, the Advance Notice states that CMS is “considering publishing the Rate Announcement in January 2021 in light of the challenges for Medicare Advantage (MA) organizations.”

With all of this haste, CMS clarified that expectations for the notices will need to be mitigated, but will be handled and called out. “This accelerated schedule does not result in changes to the data or assumptions we would typically rely on for the calculations and methodologies presented in Part I of the Calendar Year (CY) 2022 Advance Notice. The same is not true for the policies covered in Part II of the Advance Notice; should we publish Part II early, we will discuss in Part II where the schedule change might affect our Part II calculations and methodologies.”

I think we all welcome the forbearance as a means to review and provide comments while the public health emergency (PHE) continues. As most plan stakeholders are aware, management of care and capture of diagnosis has become more difficult in these times. The PHE has caused a material decline in office visits by members as well. This additional time will afford us all the opportunity to plan for 2021 management of members and model out some of our risk adjustment strategies.

Source Data Weight Shifts to 100% EDS — RAPS Exits the Equation

For CY 2022, CMS has proposed that encounter data submissions would be the only source used in risk score calculations. Risk Adjustment Process System (RAPS) would no longer be used as a submission method for CY 2022. I noted in prior memo reviews that while CMS was continuing to use inpatient RAPS data to supplant Encounter Data System (EDS) inpatient data, this would eventually come to an end as well. In this proposal, they’ve outlined that the inpatient data will now shift 100% to leveraging EDS inpatient data as the source for risk score calculation.

“CMS is committed to continuing to strengthen MA by promoting greater innovation, transparency, flexibility, and program simplification.”

CMS Called, and They Want Their 2017 HCC Model Back

As expected from prior memos, the alternative payment condition count (APCC) model known as the 2020 CMS-HCC model is proposed to be weighted at 100% for CY 2022. The 2017 CMS-HCC model would fully sunset in this proposal. This is due to the 21st Century Cures Act, which mandates a HCC count based model.

What’s Next?

The move to 100% encounter data has been forecasted for sometime now by CMS. Plans should still evaluate the revenue gaps created by full reliance on the 2020 CMS HCC model and EDS data (especially since the inpatient data that was previously supplanted by RAPS).

Episource also predicts that CMS will have a heavy focus on encounter data accuracy in the years to follow, tying EDS more closely to medical loss ratio (MLR) and accuracy of encounters submitted.

This article was revised on October 4, 2022.

Categories