Riding Off Into the RAPS Sunset

Most of us can appreciate the beauty and splendor of a beautiful sunset and all that it represents, such as the completion of a day's work and the passage of time that are reflected in these lovely quotations. There is a sunset of a different type about to occur in the Medicare Advantage space, and although it may not be as spectacular as an actual sunset, there are things to consider to ensure that there are no dark clouds on the horizon that diminish the ability to see it clearly and have a positive experience.

Since October 2010, the CMS release of every Medicare Advantage (MA) Advance Notice of Methodological Changes for the Calendar Year AKA "the Advance Notice" has been met with trepidation by Medicare Advantage organizations (MAOs). This trepidation stemmed from CMS' announcement in October 2010 of their intention to sunset the five data element Risk Adjustment Processing System (RAPS) format used by MAOs for submitting risk adjustment claims data to using the 5010 X12 837 encounter data format with many hundreds of data elements starting on 1/1/2012. Member risk scores would be calculated during the transition, which was expected to conclude by 2015, using a blend of EDPS- and RAPS-based data, with the percentage of risk score based on EDPS increasing year over year. By implementing the blending of EDPS and RAPS for risk scoring over time, CMS acknowledged that the transition to a 5010 X12 837 encounter data format with many hundreds of data elements from the five data element RAPS format would pose novel and daunting operational and financial challenges for MAOs for data completeness and accuracy; hence, the trepidation felt by MAOs with the annual release of the Notice and its announcement of the percentage of the risk score calculated from EDPS for the next payment year. CMS had originally envisioned the sunsetting of RAPS to occur by 2015, but issues with data quality management and the industry's mobilization of people, processes and technology to manage the transition took time to effectively implement. Therefore, during the transition MAOs were advised to monitor the gaps between EDPS and RAPS submissions to identify and address obstacles to submitting complete and accurate data. CMS' approach to improving data completeness and accuracy during the transition included incorporating the results of various GAO audits and OIG recommendations that prompted CMS to implement a number of metrics intended to improve data completeness and accuracy and to move the industry closer to the goal of risk score calculation based on 100% EDPS.

According to trending Centauri has done on its clients' EDPS Quarterly Report Cards, by which CMS compares its clients against their similarly-sized peers in the region, and Annual Operational Metrics, overall data completeness and accuracy has steadily improved to 98% or better submission acceptance rate for Professional, Institutional and DME. Additionally, the gaps between EDPS and RAPS are now negligible for those MAOs with best practice data management and governance programs. For the industry in general, acceptance rates are well above 90%, which bodes well for the full transition to EDPS-based risk scores with minimal impact on payment accuracy due to data completeness and quality issues. Thus, it was no surprise that the transition to 100% EDPS has finally been announced according to the recent release of the Advance Notice for PY 2022, and RAPS will finally be sunset after a long ten-year journey. Does this mean that all the people, processes and technology that support RAPS can ride off into the sunset at the stroke of midnight on 1/1/2022? No, not really. In this article, we'll explore some important things to consider as MAOs evaluate how to sunset their RAPS operations and ensure that their risk adjustment horizon is as clear as what is described in the opening quotations.

• Timing of Submission "Sweeps" Deadlines: Despite the fact that CMS announced a full cutover to RAPS for PY2022, which applies to 2021 dates of service, the way the submission deadlines operate make it unlikely that it is as simple as discontinuing the RAPS operational processes come January 1, 2022. The schedule as published below would seem to indicate that RAPS will truly not sunset until well after 1/1/2022, since PY 2022 risk scores are based on 2021 dates of service and are subject to initial, interim and final deadlines. A question was posed to CMS at their informational call on 1/19/2021 about this and accepting RAPS past 1/1/2022, but CMS indicated they would issue further specific guidance later. CMS was also asked during the call about increasing the frequency of MAO-004 reports back to MAOs, which would be supportive of MAO efforts to address completeness and accuracy issues more proactively prior to sweeps deadlines. This would be especially critical as MAOs adapt to 100% EDPS risk score calculation post-RAPS sunset, and the MAO-004 reporting and reconciliation against the MAO-002s are the key to successfully monitoring for completeness and accuracy issues that could affect risk scores. This is particularly true for those MAOs who manage their own submissions as opposed to using a vendor partner. CMS agreed that increasing MAO-004 report frequency made sense for this reason and would consider the suggestion. As the industry awaits further guidance on the timing of the RAPS sunset and the possibility of increased MAO-004 reporting, MAOS should undertake a careful reevaluation of their risk adjustment data governance strategies, as discussed in the following bullet points.