CMS
Takes Close Look at Encounter Data to Pinpoint Weak Spots (with Chart: MA
Encounter Data Submissions Continue to Rise)
Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and
business strategies about Medicare Advantage plans, product design, marketing,
enrollment, market expansions, CMS audits, and countless federal initiatives in
MA and Medicaid managed care.
By Lauren
Flynn Kelly, Managing Editor
September 21, 2017 Volume 23 Issue 18
As the volume of encounter data collected by CMS grows — reaching
an anticipated 775 million records for 2017 — the agency is working to ensure
that data are accurate and complete through analysis, communications with
Medicare Advantage organizations (MAOs) and other efforts that it will continue
to refine, officials attested during a session of the CMS Medicare Advantage
and Prescription Drug Plan Fall Conference, held Sept. 7 in Baltimore.
CMS in 2012 began collecting data from MAOs through the encounter
data system and in 2016 started phasing in EDS-based payments. For 2018, 15% of
payments will be based on EDS scoring while the other 85% will come from the
old risk adjustment payment system (RAPS). But use of the system for payment
purposes has received criticism from plans — which have reported differences
between RAPS and EDS scoring — and the Government Accountability Office, which
earlier this year asserted that CMS has made “limited progress” in validating
encounter data and that it should implement GAO’s earlier recommendation that
CMS fully assess data quality before use (MAN 1/26/17, p. 8).
Though it is still processing records for 2017, CMS expects to
collect roughly 775 million submissions this year, compared with 500 million
collected in the first year that submissions were required (see chart below),
and estimates it will have collected more than 3.2 million records between
calendar years 2013 and 2017. While some of that growth has been related to
rising MA enrollment, CMS has also observed growth in submissions per
beneficiary as the collection process matures, said Shruti Rajan, an official
with the Division of Encounter Data and Risk Adjustment Operations in the
Center for Medicare’s Medicare Plan Payment Group, during the session.
The most commonly recorded “front-end” edit from the first quarter
of 2017 as well as 2015 and 2016 has been the diagnosis code, occurring at a
rate of 0.70% in the most recent quarter. Meanwhile, of the five most
frequently occurring “back end” edits (i.e., those reflected in MAO-002 reports
sent back to sponsors), chart review duplication (1.84%) tops the list for
professional records and exact inpatient duplicate encounters (1.22%) occurs
most frequently for institutional records.
Through various communications, CMS has heard from plans about the
latter. “The reasons for the concerns are varied and many times they include
plans attempting to resubmit an encounter but with a change in diagnoses or
some of the other data fields,” said Rajan. “Our analysis indicates that the
data elements on these duplicate records might differ between the duplicate
record and the initial submission, and so we are considering options related to
this edit.”
Analysis Includes Record-Level Review
To improve the EDS, which began capturing records in 2012, CMS in
2015 implemented a two-pronged Medicare Data Integrity Plan that includes (1)
validating the completeness and accuracy of encounter data and (2)
communicating with MAOs on the best ways to improve data submissions. This
involves four “interrelated” activities: analysis of encounter data,
communication with MAOs, monitoring and compliance, said officials.
“Analysis is really the crux...that’s supporting the other
pieces,” said Monica Reed-Asante, deputy director with the Division of Payment
Policy within the Plan Payment Group. This includes taking a close look at
edits to see if they are centralized and if they are affecting certain
submitters, and to make sure they are functioning as intended, she told
attendees. In addition, the agency is conducting record-level analysis, looking
at data elements for validity and completeness, record level counts and
submission patterns. “That data element-level review is really to analyze the
accuracy of the information that is submitted in specific fields,” she said.
Moreover, CMS has tried to control for enrollment in its analysis,
so in order to assess record volume, for example, it has been comparing
encounter data records per 1,000 enrollees to fee-for-service (FFS) claims per
1,000 beneficiaries on a national and regional level. Reed-Asante said CMS
recognizes that FFS may not always be the most appropriate benchmark for this
analysis and is looking at other options now that encounter data is maturing.
For instance, it may be possible to compare records for a specific submitter
over the course of several years.
A couple of the findings of CMS’s analysis are:
·
Over
the course of four service years (2013-2016), inpatient, professional and
outpatient claims per 1,000 MA enrollees are consistently lower than for FFS
beneficiaries. As a percent of
FFS claims, MA encounter data records for inpatient claims were particularly
low, from a range of 61% in 2013 to a high of 72.5% in 2015. Analysts thought
the large differences could be due to submission issues, lower utilization or a
combination of both, and wanted to dig deeper, said Reed-Asante. They arrived at
a January 2017 study that looked at MA and FFS claims for 2010 and found that
for MA, the inpatient days were roughly 16% lower in MA than FFS. CMS used that
as a basis for adjusting the FFS benchmark, which lowered the differences so
that MA increased as a percentage of FFS from 61% to 73% in 2013, for example,
“making it look much more comparable to FFS,” said Reed-Asante.
·
CMS
also conducted an analysis of inpatient encounter data records to compare
“no-pay” claims(which most hospitals
are required to submit as part of the Disproportionate Share Hospital Payment
program). Theoretically, these claims would have an encounter data submission
in RAPS and in EDS, but when matching them on four fields, analysts found that
there is some difference in submission patterns for RAPS and encounter data for
inpatient records, although the occurrence of a no-pay event found in RAPS but
not in EDS has dropped from 20% in 2013 to 12% in 2015, she observed.
In addition to ongoing communications with MAOs (e.g., site
visits, one-on-one calls and monthly user group calls), and monitoring and
compliance activities, CMS is looking at next steps that include updating and
streamlining its guidance website to make the information for MAOs more clear
and easily accessible, added Reed-Asante.
To view a web replay of the session, visit the CMSHHSgov channel
at www.youtube.com.
MA Encounter Data Submissions Continue to Rise
SOURCE: CMS, presented at the Medicare Advantage and Prescription
Drug Plan Fall Conference, held Sept. 7 in Baltimore.
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