The Need, Benefits, and Power of Data Aggregators in Risk Adjustment
Third-Party Aggregators Explained
Data-sharingistheprovisionofdatabyadataholdertoathirdpartywiththe dataowner’sconsent.Itincludesthereusingofdatabasedoncommercialand non-commercialdata-sharingagreements.
Data-sharingincorporatesacollectionofpractices,technologies,architecture, culturalelements,andlegalframeworksthatrelatetodigitaltransactionsof anyinformationsentbetweenindividualsororganizations.
Third-partyaggregatorsareessentialfordatasharingbecausetheyserveas channelsforsecuredatasharingandpromotetrustbetweenparticipants. Theyareintermediatetechnologicalplatformsthatmanageandtransferdata flowsbetweenprovidersandconsumers.Onefunctionofaggregatorsisto developinteroperabilitybetweenparticipants.
Thethird-partyaggregatorsinvolvedinriskadjustmentare:
• RiskAdjustmentProcessingSystem(RAPS)
• EncounterDataProcessingSystem(EDPS)
ExternalDataGatheringEnvironment(EDGE)
What is Risk Adjustment Processing System (RAPS)?
RAPSistheRiskAdjustmentProcessingSystemthroughwhichrisk adjustmentdataareprocessed.MedicareAdvantage(MA)organizations submitdatainfivefieldsofthereportingsystem:
1. Dateofservicefrom
2. Dateofserviceto
3. Providertype
4. Diagnosiscode
5. Patientidentifier
Thisdataisabstractedfromclaimssubmittedbyprovidersandincludes diagnosescapturedduringinternalorvendor-contractedauditsofmedical records.AfterthedatasubmittedbyMedicareAdvantage(MA)organizations passesthechecksintheFront‐EndRiskAdjustmentSystem(FERAS),thedata issenttotheCMSdatacenterforRAPSprocessing.
RAPSperformscompleteeditingofalldetailrecordsstoredintheRAPS database.
• RAPSperformsbalancingcheckstoensurecompletefileswerereceived fromFERASbeforeeditingdataasaprecautionarymeasure.
• RAPSeditsdetailedrecordtransactions,includingHICnumber, providertype,fromdate,throughdate,anddiagnosiscode.
• Ifthedateofbirthissubmitted,RAPSalsoeditsthatfield.
What is Encounter Data Processing System (EDPS)?
In2008,theCentersforMedicareandMedicaidServices(CMS)began transitioningfromRAPSdatafilestoEDPSdatafilesasthebasisforMedicare Advantagepatientriskscores.Asof2020,datamustbesubmittedthroughthe EDPS amorecomprehensivesystemrequiringadditionalinformationto helpimprovetheoverallqualityofpatientcare.
•
UnderEDPS,unfilteredencounterdataaresubmitteddirectlytoCMS.CMS thenappliesthefilteringlogictoextractthevaliddiagnosiscodes.Diagnoses arethenusedintheriskscorecalculationprocess.
What is External Data Gathering Environment (EDGE)?
AnEDGEserverisapieceofhardwarethatperformsdatacomputationatthe end(or“edge”)ofanetwork.Anedgeservercanprovidecalculations, networking,andstoragefunctionslikearegularserver.
EDGEserversprocessdataphysicallyclosetotheend-usersandon-siteapps, sothesedevicesprocessrequestsfasterthanacentralizedserver.Insteadof sendingunprocesseddatatoandfromadatacenter,EDGEserversprocess rawdataandreturncontenttoclientmachines.Asaresult,EDGEservers performquicker,withlowerlatencyandshortloadingtimes.
CMSrequiresthatinsurancecompaniesmaintainanEDGEserverforrisk adjustment.DataontheEDGEserversareusedtoultimatelycalculatetheRA transferpayments.
ForinsurancecompaniestoperformqualityassuranceonEDGEsubmissions andtohaveamoretransparentprocesstotroubleshoot,CMSprovidesEDGE DIYsoftware,whichallowsinsurancecompaniestocalculatetheirriskscores separatelyfromthenormalEDGEprocess.
Conclusion
Riskadjustmentiscrucialinensuringprovidersarecompensated appropriatelyforaccuratelydocumentingandreportinghigh-riskpatient treatmentplans.Itisastatisticalmethodforpredictingaperson’slikelyuse andcostsofhealthcareservices.Thesethird-partyaggregatorshelpto supportdatacollectionandsharing.
Source of content: AGSHealth Blog - The Need, Benefits, and Power of Data Aggregators in Risk Adjustment
