Treat EDPS as a Risk Adjustment program…not an IT function. This Episource presentation walks you through the 3 phases of EDPS, and key aspects to keep in mind to run a successful risk adjustment program.

1. WEBINAR:
RAPS/EDPS 2016 in
Review, Lessons
Learned in Preparation
for 2017
FEBRUARY 2, 2017

2. S E N D Y O U R Q U E S T I O N S V I A T W I T T E R :
# E D P S W I T H E P I
O R
D U R I N G W E B I N A R
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3. C O M PA N Y B A C K G R O U N D
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4. 4
• Focus on Risk Adjustment Services and Software for Health plans, IPAs
and Medical Groups with extensive experience on retrospective chart
audits and quality reporting
• Established in 2006 with an Integrated Onshore/Offshore Global
Delivery Model
• Headquartered in Los Angeles, CA
• Over 1,500 Certified Medical Coders (CPC and CCS) and 50 RNs, fully
employed with the company
• HIPAA and ISO 27000, and ISO 9001 Certified with US-based data
centers. HITRUST Certification in progress.
• International Corporate Member of AAPC and AHIMA ICD-10
Certified Trainer on staff
Episource Overview
The Fastest Growing Coding
Company in the Industry

5. 5
End-to-End Solutions
For Payers
INNOVATIVE SOLUTIONS FOR RISK ADJUSTMENT ORGANIZATIONS
• Medical Coding and Retrospective
Chart Reviews — Medicare,
Medicaid, HIX/Commercial
• Medical Record Retrieval
• HEDIS Medical Record
Abstraction
• HEDIS Consulting Services
Quality ImprovementRisk Adjustment ServicesRisk Adjustment Software
• EpiEncounter. RAPS/EDPS
Reconciliation, Error Resolution,
and Financial Analytics
• EpiAnalytics. HCC Analytics and
Suspecting
• EpiConnect. Real-time updates on
all record retrieval and coding
projects

6. tspaeth@episource.com
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TIM SPAETH
VP, PAYER SOLUTIONS
714.000.0000
“I lead the RAPS/EDPS Submissions and
Analytics services and drive the company’s
Risk Adjustment Consulting Practice.
I provide strategy around Analytics offerings
for both Medicare and ACA.”

7. Treat EDPS as a Risk
Adjustment
program…not an IT
function.
THREE PHASES OF EDPS
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1. Submissions
 Handling of data
 Formatting of data
 Submission to CMS
 Handling of various response files from CMS
2. Error Management
 What’s the error?
 Who can fix it?
 Where to fix it?
3. Analytics
 Isolate HCC encounters
 Focus on Financial Impact
 Provider-level Analytics

8. S U B M I S S I O N S
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9. SUBMISSION SUMMARY
• Understand all data sources
• Claims/encounters
• Prospective Programs
• Retrospective Programs
• Have one submission system for both RAPS & EDPS
• Continue to submit even after deadline
• 1/31 for RAPS
• 5/1 for EDPS (time to put in place short-term, but impactful
fixes)
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Submissions

10. CHART AUDIT INVENTORY
• Linked is always best
• CMS will probably require linked in future
• Charts data typically has significant $ impact
• Submit it unlinked to ensure you get the proper
payment
• Be careful of CPT codes
• Linked data can pull in non-RA codes
• Unlinked use proper RA codes
• The Real Test is if the Dx code is on the Chart
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Charts – Linked vs. Unlinked

11. E R R O R M A N A G E M E N T
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12. ERRORS - 999
• 999 Errors should be caught before
submission
• One small error can cause the entire file to
fail
• CMS’ 999 reply aren’t always insightful or
intuitive
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Error Management

13. • Work errors with potential financial
impact first
• Identify encounters with HCCs
• Identify encounters where that HCC does
not exist already from a different
encounter
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Error Management VALUE LOSS: ERRORS BY TYPE

14. ERRORS BY TYPE
• Need other departments’ inputs and help
(enrollment, claims, network management,
etc.
• Utilize existing RAPS process to fix errors
• Make it simple for the other departments to
understand the error
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Error Management

15. • Fix error in EDPS submission vs. Source system
• $ million question
• 2015 DOS – fix submission, source later
• 2016/17 DOS – source and/or combination of
source/submission
• Identify systemic problems
• If 999 errors still exist, scrub data before
submitting
• Understand claim system limitations
• Cost/benefit analysis of upgrading claims
system or using fixing in front end encounter
system
• Does the data that needs to be fixed affect
payment/adjudication of claim?
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Error Management

16. A N A LY T I C S
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17. • RAPS can be used as the baseline for
financials and HCCs
• MAO-002s should be used for the EDPS
baseline combined with CMS filtering logic
• MAO-004s are improving but still flawed
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MAO-002 vs. MAO-004
vs. RAPS

18. • CMS has delayed EDPS submissions to May
1, 2017
• Normal true-up of RAPS data submitted since
March 2016 sweep through January 2017
sweep
• Reversal of RAPS based payment from 100%
to 90%
• Complete payment of EDPS of 10%
oOnus will be on plans to show
discrepancies between accepted EDPS
data and actual payment.
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Final Payment 2016 (2015
DOS)
R A P S / E D P S 2 0 1 6 I N R E V I E W , L E S S O N S L E A R N E D I N P R E P A R A T I O N F O R 2 0 1 7

19. • Need to Delete in both RAPS & EDPS.
• If timing is in question, focus on submitting Adds
prior to sweep deadline.
• CMS will always accept $ back, but limit health
plans on payment.
• 2014 DOS need to be deleted for EDPS!!!
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Don’t Forget Deletes

20. • Health plans and provider groups must work
together
• Share the error reports (999, 277, MAO-002)
• Clear understanding what is needed from
providers for the EDPS submission
• Compare Providers to a benchmark and/or
other similar Providers
• Providers and Groups must be proactive in
managing their data before it is sent to the
health plan
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Provider relationships will
be critical
R A P S / E D P S 2 0 1 6 I N R E V I E W , L E S S O N S L E A R N E D I N P R E P A R A T I O N F O R 2 0 1 7

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