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Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications
Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications
Starting in 2008, CMS began the effort to transition from using Risk Adjustment Processing System (RAPS) data files to using Encounter Data System (EDS) data files as the basis for Medicare Advantage member risk scores. The shift to EDS data for calculating risk scores poses substantial financial risks for MAOs that are unprepared or ill-equipped to submit and monitor the EDS submissions. For many MAOs, risk-adjusted revenue makes up over 80% of total Medicare Advantage revenue. MAOs may be at significant financial risk if they have declines in risk scores and the revenue associated with their risk scores.

Milliman completed a study of how the transition from RAPS data to EDS data is affecting the payment year (PY) 2016 risk scores and revenue for Medicare Advantage. Fifteen MAOs participated in the study, reflecting a cross-section of small and medium size organizations and representing over 900,000 members in 154 plans. Study participants saw a median decrease in risk scores of 4% when comparing EDS scores with RAPS scores. 2017 mid-year risk score updates will be based only on RAPS (not on EDS, RAPS, and Medicare fee-for-service (FFS) claims). MAOs have more time to review their EDS diagnosis submissions between now and May 1, 2017, in order to improve any deficiencies in their EDS submission processes. Despite revisions from CMS, these issues are not fully resolved. There are a number of steps MAOs should consider regarding their diagnosis submissions to address these issues.

Please join us Wednesday, February 22nd, 2017 at 1 PM Eastern as Milliman's Deana Bell, David Koenig and Charlie Mills review their RAPS to EDS transition study and discuss transition problems and how Medicare Advantage organizations should respond in the HealthcareWebSummit event: Medicare Advantage Risk Score Transition - RAPS to EDS Impact, Issues and Implications.
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