Background

CMS began capturing encounter data several years ago from plans. The long- term intent of using this data was for risk adjusted payment purposes, as well as to be able to evaluate services rendered for frequency, by zip code, demographics and providers.

CMS has been monitoring the data provided and initially put forth a staged approach moving towards 100 percent encounter data reporting informing payment, with the eventual goal being that all risk-adjusted payments would be derived from the encounter data. Plans have raised serious concerns to CMS about this approach because of the challenges in collecting accurate data.

This year (2017), CMS has been using 75 percent RAPS codes and 25 percent encounter data codes for payment, but is reducing reliance on encounter data for 2018 to 85 percent RAPS and 15 percent encounter data as they continue to work with plans on improving encounter data. This does not mean CMS is not committed to moving forward to the 100 percent encounter data usage, but perhaps is finally recognizing the encounter challenges plans are facing.

CMS Compliance Requirements and Common Challenges

CMS has limited requirements regarding encounter data submissions beyond the 837-format requirement. Currently, the frequency of encounter data submission is based on a plan’s membership as of February enrollment. However, given data size limitations, plans are encouraged to submit more frequently than required, and a best practice would be to submit on a daily basis.

CMS expects plans to conduct self-assessments to validate the completeness of their encounter data, as well as to perform a comparison between the volume of encounters with fee-for-service (FFS) payments. Encounter Report Cards are the primary tool for communicating CMS’ analyses of encounter data completeness and quality to submitters and are distributed via HPMS. Plans should be using the report cards from CMS to compare to their own findings.

Despite the limited compliance requirements around encounter data, there are still many challenges. One challenge plans face is the sheer increase in magnitude of file size, from the RAPS file which requires minimal fields to submit vs the encounter file in a full 837 format. Another factor is populating that file from fields in the plan core system. Additional mapping of system fields may be required to ensure all required data is populated.

Plans are also facing a challenge with provider education. There is a disconnect between provider billing and providers’ understanding that encounters are being used for more than just their claims payment. Plans will need to aggressively conduct provider education to minimize submission errors on their part.

Currently, there are a number of reports available to help plans ensure the submitted encounter files are formatted correctly and which records will be used for risk adjustment. Putting processes in place to proactively monitor and correct errors on those files is critical for a plan’s success in getting the proper risk adjustments for their membership.

What Does this Mean for Plans?

It’s important that plans take advantage of this slight reprieve from CMS to work aggressively to capture complete encounter data. As CMS moves to reliance on just encounters for payment purposes, it’s important to ensure those are complete and accurate.

Get started now! The move to utilize encounter data for risk adjustment payment is not far away, so getting a start on implementing the right policies, procedures and processes is critical for readiness. 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 to assist is a great option to help you understand gaps, provide staff education and help implement processes, so you are prepared for the transition.

BluePeak Can Help

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 PDE data and to 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 for more information about how they can also help you understand your Encounter gaps and help remediate them before your risk adjustment payments are dependent on them.