Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications

      
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Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications 
 
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Overview
Starting in 2008, CMS began the effort to transition from using Risk Adjustment Processing System (RAPS) data files to using Encounter Data System (EDS) data files as the basis for Medicare Advantage member risk scores. The encounter data submitted by Medicare Advantage organizations (MAOs) was first used for risk adjustment in the 2015 payment year (PY), where encounters with dates of service from calendar year (CY) 2014 were used as a supplemental source of diagnoses to those submitted through RAPS. CMS has committed to using EDS data as the sole basis of payment after a multiyear transition of blending risk scores that are calculated from RAPS and EDS.

The diagnosis submission process for EDS is significantly different from RAPS and represents a large shift in the responsibilities that both CMS and MAOs have with respect to proper coding, filtering, and data submission. The shift to EDS data for calculating risk scores poses substantial financial risks for MAOs that are unprepared or ill-equipped to submit and monitor the EDS submissions. For many MAOs, risk-adjusted revenue makes up over 80% of total Medicare Advantage revenue. MAOs may be at significant financial risk if they have declines in risk scores and the revenue associated with their risk scores. During the transition to EDS, MAOs must be knowledgeable about EDS, understand the impact of the transition on revenue, and monitor and review EDS submissions closely to ensure their revenue will not be negatively affected.

Milliman completed a study of how the transition from RAPS data to EDS data is affecting the payment year (PY) 2016 risk scores and revenue for Medicare Advantage. Fifteen MAOs participated in the study, reflecting a cross-section of small and medium size organizations and representing over 900,000 members in 154 plans. The study relied on the revised EDS MAO-004 files that the Centers for Medicare and Medicaid Services (CMS) released late in October 2016. The participants in the study saw a median decrease in risk scores of 4% when comparing EDS scores with RAPS scores.

CMS has released a new memo regarding risk adjustment data deadlines. The December 29, 2016, memo from CMS announced two changes to the data submission and risk score calculation schedules that were previously released. Submission deadline for EDS data has been extended for the 2016 final risk scores: The final day to submit encounter data for use in PY 2016 risk scores has been extended to May 1, 2017 (updating the original deadline of January 31, 2017). The RAPS submission deadline was not extended from January 31, 2017.

2017 mid-year risk score updates will be based only on RAPS: As a departure from original plans, CMS will not calculate the 2017 mid-year risk scores using EDS, RAPS, and Medicare fee-for-service (FFS) claims. MAOs have more time to review their EDS diagnosis submissions between now and May 1, 2017, in order to improve any deficiencies in their EDS submission processes. In addition to the reduced risk scores and revenue that are expected to result from this transition, MAOs have been challenged with difficult problems related to EDS data submission and receiving information in a timely manner. Despite revisions from CMS, these issues are not fully resolved. There are a number of steps MAOs should consider regarding their diagnosis submissions to address these issues.


Please join us Wednesday, February 22nd, 2017 at 1 PM Eastern as Milliman's Deana Bell, David Koenig and Charlie Mills review their RAPS to EDS transition study and discuss transition problems and how Medicare Advantage organizations should respond in the HealthcareWebSummit event: Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications.
Learning Objectives

After attending this webinar, attendees will be able to:

  1. Review the current processes, deadlines and requirements regarding the RAPS to EDS transition
  2. Examine the results of the Milliman study of the impact of the transition on MAOs.
  3. Consider the impact, issues and implications of the RAPS to EDS transition going forward. 
  4. Identify five transition problem areas the MAOs are still struggling with.
  5. Ascertain various steps MAOs should consider regarding their diagnosis submissions to address these issues.
  6. Engage in interactive learning through online question submission, attendee feedback and opportunity for follow up questions, and networking with attendees, faculty and other professionals through dedicated LinkedIn group.
Who Should Attend

Interested attendees would include:

  • C-Suite Executives
  • Medicare Advantage Executives and Staff
  • Analytics Executives
  • Risk Adjustment and Encounter Data Submission Managers
  • Provider Network Operations Executives and Staff
  • Actuarial Executives and Staff
  • Finance Executives and Staff
  • Managed Care Executives and Staff
  • Planning and Strategic Executives and Staff
  • Business Intelligence Staff
  • Regulatory and Compliance Executives
  • Other Interested Parties

Attendees would represent organizations including:

  • Medicare Advantage Organizations
  • Provider Networks
  • Government
  • Pharmaceutical Organizations
  • Solutions Providers
  • Associations, Institutes and Research Organizations
  • Media
  • Other Interested Organizations
Registration
Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications
 
  Individual Registration Fee: $195. Post-event materials, with video syncing slides and recorded audio, plus presentation pdf file: $45 for attendees; $240 for non-attendees after the event. Register online or download the event brochure.
 
 
 
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Faculty
 
Deana Bell

Deana Bell, FSA, MAAA
Consulting Actuary
Milliman, Inc.

  Deana is an actuary specializing in health care consulting in the Seattle office of Milliman. She joined the firm in 2005.

Deana's actuarial experience includes pricing, rating, reserving, medical underwriting, benchmarking, and risk adjustment. Deana works primarily with group health care programs, including commercial, Medicare Advantage, employer groups, and Veterans Health Administration. Deana has extensive expertise in morbidity risk scoring and analyses as well as utilizing Milliman's Health Cost Guidelines (HCG) and health care claims data grouper to support health care experience benchmarking analyses for her clients.

Her recent client assignments include: Medicare Advantage bid development and support; Development of pricing models and rating; Retrospective cost and utilization review; Risk adjustment models and other predictive modeling; and Pricing and benefit relativities.

Deana has a BA (summa cum laude) in Mathematics, from Lewis & Clark College. She is a Fellow, Society of Actuaries and a Member, American Academy of Actuaries.
 

 
Charlie Mills

Charlie Mills, FSA, MAAA
Principal, Consulting Actuary
Milliman, Inc.

 

Charlie is a principal and consulting actuary with the Health practice in Milliman's Seattle office. He joined the firm in 2003.

Charlie's experience as a healthcare consultant includes: Medicare Advantage bid preparation; Commercial and Exchange rate filings; Small and large group pricing;
Network and ACO development; and Provider contracting and reimbursement.

Charlie has significant experience working with both health plans and providers. He has prepared Medicare Advantage bids since 2008, is an expert in Medicare fee schedules and provider reimbursement, and has had the opportunity to work with providers participating in Medicare's Pioneer ACO and Next Generation ACO programs.

In addition, Charlie provides clients the tools and expertise needed to leverage data in their decision-making processes. Charlie has played a key role in the development of a number of Milliman products, including the Health Cost Guidelines (HCG) Grouper, GlobalRVUs, and Medicare Repricer.

Charlie has a BS, in Applied and Computation Mathematical Sciences, from the University of Washington. He is a Fellow, Society of Actuaries, and a Member, American Academy of Actuaries.
 


 
David Koenig

David Koenig, ASA, MAAA
Associate Actuary
Milliman, Inc.

 

David Koenig is an Associate Actuary with the Health practice in Milliman's Seattle, office.


 
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