WEBINAR:RAPS/EDPS 2016 in Review, Lessons Learned in Preparation for 2017 FEBRUARY 2, 2017

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S E N D Y O U R Q U E S T I O N S V I A T W I T T E R :

# E D P S W I T H E P IO R

D U R I N G W E B I N A R

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C O M PA N Y B A C K G R O U N D

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• Focus on Risk Adjustment Services and Software for Health plans, IPAs and Medical Groups with extensive experience on retrospective chart audits and quality reporting

• Established in 2006 with an Integrated Onshore/Offshore Global Delivery Model

• Headquartered in Los Angeles, CA

• Over 1,500 Certified Medical Coders (CPC and CCS) and 50 RNs, fully employed with the company

• HIPAA and ISO 27000, and ISO 9001 Certified with US-based data centers. HITRUST Certification in progress.

• International Corporate Member of AAPC and AHIMA ICD-10 Certified Trainer on staff

Episource Overview

The Fastest Growing Coding Company in the Industry

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End-to-End SolutionsFor Payers

I N N O VAT I V E S O L U T I O N S F O R R I S K A D J U S T M E N T O R G A N I Z AT I O N S

• Medical Coding and Retrospective Chart Reviews — Medicare, Medicaid, HIX/Commercial

• Medical Record Retrieval

• HEDIS Medical Record Abstraction

• HEDIS Consulting Services

Quality ImprovementRisk Adjustment ServicesRisk Adjustment Software

• EpiEncounter. RAPS/EDPS Reconciliation, Error Resolution, and Financial Analytics

• EpiAnalytics. HCC Analytics and Suspecting

• EpiConnect. Real-time updates on all record retrieval and coding projects

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tspaeth@episource.com

T I M S PA E T HVP, PAYER SOLUTIONS

714.000.0000

“I lead the RAPS/EDPS Submissions and Analytics services and drive the company’s Risk Adjustment Consulting Practice. I provide strategy around Analytics offerings for both Medicare and ACA.”

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Treat EDPS as a Risk Adjustment program…not an IT function.

T H R E E P H A S E S O F E D P S

1. Submissions Handling of data Formatting of data Submission to CMS Handling of various response files from CMS

2. Error Management What’s the error? Who can fix it? Where to fix it?

3. Analytics Isolate HCC encounters Focus on Financial Impact Provider-level Analytics

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S U B M I S S I O N S

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SUBMISSION SUMMARY

• Understand all data sources

• Claims/encounters

• Prospective Programs

• Retrospective Programs

• Have one submission system for both RAPS & EDPS

• Continue to submit even after deadline

• 1/31 for RAPS

• 5/1 for EDPS (time to put in place short-term, but impactful fixes)

Submissions

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CHART AUDIT INVENTORY

• Linked is always best

• CMS will probably require linked in future

• Charts data typically has significant $ impact

• Submit it unlinked to ensure you get the proper payment

• Be careful of CPT codes

• Linked data can pull in non-RA codes

• Unlinked use proper RA codes

• The Real Test is if the Dx code is on the Chart

Charts – Linked vs. Unlinked

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E R R O R M A N A G E M E N T

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ERRORS - 999

• 999 Errors should be caught before submission

• One small error can cause the entire file to fail

• CMS’ 999 reply aren’t always insightful or intuitive

Error Management

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• Work errors with potential financial impact first

• Identify encounters with HCCs

• Identify encounters where that HCC does not exist already from a different encounter

Error Management VALUE LOSS: ERRORS BY TYPE

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ERRORS BY TYPE

• Need other departments’ inputs and help (enrollment, claims, network management, etc.

• Utilize existing RAPS process to fix errors

• Make it simple for the other departments to understand the error

Error Management

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• Fix error in EDPS submission vs. Source system

• $ million question

• 2015 DOS – fix submission, source later

• 2016/17 DOS – source and/or combination of source/submission

• Identify systemic problems

• If 999 errors still exist, scrub data before submitting

• Understand claim system limitations

• Cost/benefit analysis of upgrading claims system or using fixing in front end encounter system

• Does the data that needs to be fixed affect payment/adjudication of claim?

Error Management

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A N A LY T I C S

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• RAPS can be used as the baseline for financials and HCCs

• MAO-002s should be used for the EDPS baseline combined with CMS filtering logic

• MAO-004s are improving but still flawed

MAO-002 vs. MAO-004 vs. RAPS

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• CMS has delayed EDPS submissions to May 1, 2017

• Normal true-up of RAPS data submitted since March 2016 sweep through January 2017 sweep

• Reversal of RAPS based payment from 100% to 90%

• Complete payment of EDPS of 10%

oOnus will be on plans to show discrepancies between accepted EDPS data and actual payment.

Final Payment 2016 (2015 DOS)

R A P S / E D P S 2 0 1 6 I N R E V I E W, L E S S O N S L E A R N E D I N P R E PA R AT I O N F O R 2 0 1 7

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• Need to Delete in both RAPS & EDPS.

• If timing is in question, focus on submitting Adds prior to sweep deadline.

• CMS will always accept $ back, but limit health plans on payment.

• 2014 DOS need to be deleted for EDPS!!!

Don’t Forget Deletes

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• Health plans and provider groups must work together

• Share the error reports (999, 277, MAO-002)

• Clear understanding what is needed from providers for the EDPS submission

• Compare Providers to a benchmark and/or other similar Providers

• Providers and Groups must be proactive in managing their data before it is sent to the health plan

Provider relationships will be critical

R A P S / E D P S 2 0 1 6 I N R E V I E W, L E S S O N S L E A R N E D I N P R E PA R AT I O N F O R 2 0 1 7

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QUESTIONS?

CONTACT USsolutions@episource.com