On April 2nd, CMS released the CY 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. The primary change grabbing all the headlines is the higher than expected increase to average payments from 1.84 percent in the proposed rule to 3.4 percent. But another important takeaway is CMS confirming the increased use of encounter data to 25 percent for 2019, decreasing RAPS to 75 percent.
Accuracy of Encounter Data
For performance year 2017, Pareto Intelligence’s Data Integrity solution was used to evaluate the end-to-end completeness and accuracy of encounter data through to RAPS and EDS submission for over two million MA beneficiaries. Relevant to this news, below we’ve highlighted some key takeaways from this extensive work:
- Medicare Advantage Organizations (MAOs) on average have a $30-$50 PMPY data quality issue, with some plans as high as $200-$350 PMPY
- Over 80% of data quality issues identified were EDS related, though accounting for just under half of MAOs’ financial exposure
- Over 70% of issues occurred pre-submission, meaning that encounters or critical data components, like diagnoses, found in pre- or post-adjudicated claims/encounters were never submitted
- Unresolved EDS errors accounted for over 20% of overall financial impact
- RAPS data quality issues are still material, accounting for roughly half of the overall RAF degradation identified. Though CMS’ reliance on RAPS is decreasing, it remains an area of continued difficulty for plans and presents heightened compliance concerns as MAOs and their vendors determine what is scoreable.
Preventing these potential data quality issues requires proactively ensuring that all information received is transferred through health plans’ multiple systems and processes, and is ultimately submitted and accepted by CMS without any data degradation. Plans who do not evaluate data completeness and accuracy through the entire process could be leaving significant money on the table.
The increased use of encounter data by CMS is only one takeaway from the Final Call Letter significantly impacting MAOs. For more information or to discuss further impacts of CMS’s Final Call Letter, contact Brandon Solomon at bsolomon@paretointel.com.