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CMS Increases Percentage of Encounter Data on Which MA Plans’ Payments are Based

By May 15, 2018May 17th, 2018CMS, FWA, Part D, PDE, RAPS

According to the Final Call Letter, the Centers for Medicare and Medicaid Services (CMS) will increase the percentage of encounter data, on which part of Medicare Advantage plans’ pay is based, from 15 percent to 25 percent in 2019. As CMS increases reliance on encounter data for payment purposes, plans will need to increase their vigilance to ensure encounter data submissions are complete and accurate.

In 2017, CMS used the same percentages as will be used in 2019 – 75 percent Risk Adjustment Payment System (RAPS) and 25 percent encounter data for payment. This year (2018), CMS reduced reliance on encounter data to 85 percent RAPS and 15 percent encounter data, perhaps in response to concerns from plans regarding CMS’ staged approach to move toward 100 percent encounter data reporting informing payment.  Despite the challenges plans continue to face collecting and submitting this data, CMS continues to move forward with increased attention on compliance for submission of accurate encounters and use of data for payments. CMS is continuing to use listening forums for plans and CMS to engage and work to resolve the challenges, but plans must realize this requirement is not going away.

Common challenges plans experience with improving their encounter data include:

  • Encounter data size limitations and frequency of submissions
  • CMS-required 837-format file size and population of the file from fields in the plan’s core system
  • Provider education to reduce encounter data submission errors

BluePeak Can Help

Often plans do not fully understand their gaps associated with risk adjustments and encounter data because of the low percentage used for payment purposes. Utilizing industry expert resources is a great option to help you understand gaps, provide staff education and help implement processes, so you are prepared for the increase in the percentage of encounter data used by CMS for payment.

BluePeak has extensive experience evaluating plan RAPS and encounter processes, policies and procedures, and reports, including vendor processes, to ensure that they have an efficient and compliant process. In addition, BluePeak has the ability and expertise to load all your Part D prescription drug event (PDE) data and identify possible situations where the beneficiary’s encounter data is not consistent with the submitted PDE data. The PDE analysis would identify possible situations of Fraud, Waste and Abuse (FWA) where the encounter data may be overreported, as well as possible situations where the encounter data is not being captured for unhealthy or sick beneficiaries.

Contact BluePeak at (469) 319-1228 or for more information about how we can help you identify and remediate your encounter gaps, as your risk adjustment payments become more dependent on them.