The Problem: $6 Million in Lost Revenue

The CMS transition from RAPS to EDS creates revenue risk and increased expense for health plans. For example, a 10% drop in EDS submission accuracy can result in as much as $6 million in lost revenue. Our solution mitigates those risks and includes more than encounter submission and receipt of CMS responses in the standard formats. Our solution also recognizes the importance of accurate data submission to maintain proper revenue recognition, and therefore includes full receipt of the client’s pre and post-adjudicated claims data, data quality editing, cleansing and transformation, data certification, a queue and workflow for online error exception handling, reporting and required continuous improvement as CMS edits and data certification processes are modified.

The Solution: RAPS & EDS 

Features

  • Reconciliation and discrepancy management
  • Comparative analysis of RAPS to EDS outcomes
  • Robust standard and ad-hoc reporting
  • Data quality metrics
  • Recurring data edit exception identification for system of record enhancement consideration
  • One set of client data for both RAPS and EDS submissions

Benefits

  • Eliminates the need to manage and staff dual processes during the transition period
  • All elements of a fully optimized and compliant risk adjustment program
  • Staff with an intimate understanding of the CMS rules, guidelines and FAQs as well as a detailed understanding of the encounter data used
  • Automated, prompt and accurate solution

Next Steps

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