Tools to Analyze and Reconcile Your Submission Data – Best Practice Toolbox for Risk Adjustment Implementation, Part 4

Tools to reduce system and submission errors

Part four of a four-part series of CMS Best Practices Implementation

Centauri Health Solutions’ Director of Product Strategy – Dawn Carter

If you have been following my articles on building stronger data submission programs, your Risk Adjustment renovation toolbox should be rather heavy by now! This is my final article in a four-part series where I review a dozen CMS best practices and provide actionable strategies.

In my third article, I shared tools to help you reduce system and submission errors. My recent webinar provided an overview of my first two articles – and the tools needed for stronger provider partnerships.

This final article will arm you with a few more tools to make sure your data and your submission plan measure up – honing your submission skills through education, analysis and reconciliation.

CMS Best Practice Tool #10 – Instruction Guide

As any do-it-yourselfer has learned while attempting a renovation project, it’s important to take the time to carefully go over the instructions before getting started. And, if you have questions, turning to others with applicable experience can mean the difference between success and failure.

That’s why I cannot stress enough that you take the time to participate in CMS User Group calls to learn the latest details about submitting data to the EDPS and RAPS.

Who should be on the call – or reviewing those instructions?

Who participates from your team is just as important as the actual participation. Involving people who have no real need to be there can be counterproductive.

The team members who need to participate include the person who has overall responsibility for the EDPS/RAPS submission process, and the person who has overall responsibility for risk adjustment operations.

Also, it goes without saying that anyone functioning as the lead SME for data submission and risk adjustment should attend. Notice I said lead SME – not an army of SMEs. These leads may be one and the same, depending upon how your operations are organized.

Ensure that attendees understand the organizational impact of whatever information CMS imparts in these sessions, as well as in the HPMS memos that CMS regularly sends out on data submission and risk adjustment. Be sure to communicate those impacts downstream to affected departments and ensure the implementation of any necessary changes.

Call follow-up – sharing those instructions

Of course, it does no good to participate in these calls and then do absolutely nothing with the information. Why read the instructions if you don’t share with your team – and follow them?!

Every call should be followed by an internal debrief of the information. CMS does a good job of sending the associated slide deck to anyone registered for the webinar whether they attend or not. They rarely deviate from presenting anything that is not on the slide deck, except the Q&A that takes place after their main presentation.

Someone attending the call needs to have the responsibility for doing the following:

  • Summarize the content in terms of impact: Your point person needs to not only summarize the slide deck content, but also classify it in terms of organizational impact. Highlight items that may be significantly impactful to operations (such as failure to implement results in rejections, changes to deadlines, etc.) and those not significantly impactful, but things to watch for in the future.
  • Distribute to all pertinent stakeholders: Your leader also needs to be able to identify and include other internal stakeholders involved in data submission and risk adjustment to ensure all pertinent team members are in the loop.

CMS Best Practice Tool #11: Measuring Tape

Next, you really need to pull out your measuring tape to see how your encounter data submissions measure up.
This is pretty nebulous, but the question health plans should ask is, ‘Do I know where my encounters are at any given point in time, and can I get that information easily?’

If you were asked by leadership to tell them where your organization stands with the completeness and accuracy of submissions, could you quickly tell them? If the answer to these question is ‘No’ or ‘I don’t know’, any analysis you are doing is probably not the right kind.

Since the submission of encounters data reveals to a health plan the business problems of compliance and payment accuracy, any analysis done needs to laser focus on how well these particular problems are being solved.

This does not have to be complicated, and this analysis is an example of when more is not necessarily better. A little bit of legwork goes a tremendously long way, and CFOs don’t like to be overwhelmed with too much information.

A simple dashboard with the following is all you need:

  • Your “claims universe” – This is the total eligible adjudicated claims volume that should be sent to CMS for the given payment year. Note that EDPS and RAPS will differ in what is eligible to be sent because fewer types of services are required for RAPS than EDPS. This should also include the number of retrospective chart reviews done where an addition and/or deletion was found, prospective assessments that are eligible for submission, and any other sources for supplemental data submission.
  • Accepted Submissions – Of the total eligible adjudicated claims volume, the overall percentage of accepted submissions should be highlighted. This is the number that got all the way through MAO-002 processing and were assigned an ICN.
  • Risk Score Impact – For the volume that is showing a Rejected status, whether it is at the 999, 277CA or MAO-002 level, be sure to indicate the risk score impact for the members. This score captures the impact if that data doesn’t get corrected and submitted – and also for any delta between the total claims universe and what is eligible to be sent but hasn’t been.

    This score is what CFOs really want to know in terms of the success or failure of data submissions operations. If you can’t produce that impact or don’t know how to do that, find a vendor or consultant who can help you do that. Hint: You’ll have to compare the MAO-002s, MORs and MAO-004s, and run the risk models. I guarantee you that the cost of such a vendor or consultant will be more than paid for by the risk adjusted dollars gained by this. If your current vendor is not doing this, then it’s probably time to get a new one who does.

CMS Best Practice Tool #12: Drill

Finally, it’s important to use that power drill and drill down to reconcile MAO-002 and MAO-004 reports. This also requires a dashboard and the likely assistance of the person who supports risk adjustment analytics.

This MAO comparison allows health plans to know that, of the encounters accepted at the MAO-002 level, those diagnoses present on the encounters that are allowed for risk adjustment. It also allows plans to identify diagnoses that do not pass the CMS filtering logic and the reason why they are not eligible. Both are critical data points needed by risk analytics.

Your Final CMS Best Practice DIY Tip: Use That Hammer!

Remember, having the right tools is just the start to a successful renovation project.

Make sure you and your team keep a DIY mindset in place – and constantly watch for improvements that need to be made to your submission process. As your organization changes from year to year, so may the required tools from your toolbox.

As the tools become more familiar to you and your team, you will be able to hammer these best practices into place. They will become standard practice for your organization and help ensure that your data submission program is a model of success moving forward.

Happy renovating!