On January 26th, the Centers for Medicare and Medicaid Services (CMS) announced an extension to the Final Reconciliation deadline for Payment Year (PY) 2017 Risk Adjustment Processing System (RAPS) data submissions. The previously reported deadline of January 31, 2018 will remain an Interim Final Reconciliation deadline, while the RAPS PY2017 Final Reconciliation deadline is now May 4, 2018.

Risk Adjustment Data Collection

The CMS notification cites extreme weather events causing difficulties in risk adjustment data collection and submission as the reason for the deadline extension. The memo does not include a deadline for Encounter Data System (EDS) submissions, which CMS still has not yet defined.

This deadline extension presents an opportunity for Medicare Advantage Organizations (MAOs) to evaluate the completeness and accuracy of their RAPS submission data. Our experience assessing end-to-end data integrity for numerous health plans around the country has shown that even small risk loss can yield significant financial opportunity. On average, we've found data integrity issues result in approximately $50 per member per year (PMPY) revenue loss, with some plans losing over $350PMPY. For RAPS-specific issues, our findings indicated an average loss of $26PMPY and, in some cases, up to $300PMPY. EDS losses averaged $24PMPY, with some plans incurring up to $140PMPY revenue loss.

What can MAOs do?

Considering the potential recovery opportunity, MAOs should take advantage of CMS' RAPS deadline extension to reevaluate submissions and improve risk score accuracy.

Complete an end-to-end data integrity assessment. Evaluating end-to-end data integrity ensures that all information received (e.g., billing 837s, supplemental records from chart reviews, etc.) is being submitted and accepted by CMS without any degradation. Obtaining data extracts from each point of the data process may be administratively taxing, so assess data availability and complete the evaluation in stages, if necessary. Just evaluating whether all post-adjusted claims data is being submitted and accepted can uncover significant improvement opportunities.

Root cause investigation to prioritize remediation. Step one is determining where in the process data quality issues have occurred. Step two is figuring out why. Root cause investigation can be time consuming; therefore, applying advanced data science and analytics can cluster encounters around common themes (e.g., diagnosis truncation, particular claims types, etc.) to expedite root cause investigation and remediation efforts.

Establish ongoing quality controls. Internal systems and regulatory reporting requirements are continually changing. It's critical to have proven quality controls in place to ensure the completeness and accuracy of ongoing submissions. Adequate quality controls evaluate the integrity of an MAOs data throughout the end-to-end process, not just on the submission and error resolution phase of the process, while providing timely and actionable insights to correct issues before report deadlines.

Contact Brandon Solomon at bsolomon@paretointel.com to learn how Pareto Intelligence's unique analytics platform can help you uncover data quality improvement opportunities in advance of this new deadline.