In the proposed 2020 Advanced Notice and Call Letter, CMS proposed to continue its transition to use encounter data to calculate MA plan 2020 risk scores. CMS proposed to calculate 2020 risk scores using a blend of 50% RAPS data and 50% EDS data, up from the current blend of 75% RAPS/25% EDS.

Previous Avalere research found that 2016 risk scores were 3% lower when using EDS data to calculate risk scores versus using RAPS data. CMS’ most recent estimate of the impact of the transition is only -0.06% but incorporates RAPS inpatient data in the EDS risk scores and masks the true size of the impact. Once CMS phases out the RAPS system, these RAPS-sourced hospital inpatient data will become unavailable, which will in turn negatively affect plan revenue unless the underlying gaps are addressed.

While CMS continues to transition risk score calculation from using RAPS to using EDS, plans should evaluate internal operations to ensure they are equipped to handle the differences between the 2 systems to minimize the impact on plan operations, risk score accuracy, and thus financial performance.

Avalere has identified 4 steps plans should do now to ensure future readiness:

1. Systematically compare plan risk programs against the full list of requirements for EDS submission. Avalere uses our proprietary EDS Compliance Matrix to identify gaps in current programs versus EDS requirements set forth by CMS.
2. Conduct an impact analysis using plan claims data of risk score calculation using RAPS data versus EDS data. Running claims data for a given date of service (DOS) using both claims sources will highlight plan-specific risk score differences and help uncover areas for accuracy improvement.
3. Evaluate plan policies, procedures, and infrastructure to ensure current operations support the technical and operational differences between RAPS and EDS submission. Avalere typically evaluates program documentation, technology infrastructure, products used, filtering logic, pre-edits, edits, reports from CMS, and internal reporting and analytic systems to ensure operational readiness.
4. Assess tools used for collecting supplemental data and processes to support supplemental data submission starting with collection from physician offices all the way through data submission. Plans should analyze different sources of supplemental data gathered through prospective and retrospective programs to ensure the full array of supplemental data is being collected and then submitted.

CMS is likely to continue on its glide path toward 100% utilization of EDS for risk score calculation. Thus, plans should act now to mitigate any impact to plan operations and ensure risk score accuracy under new risk score calculation methodologies.

To learn more about Avalere’s capabilities in this area, connect with us.

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