CMS Encounter Data to HEDIS® Tie Out

Medicare Advantage plans:

With the ongoing transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS) for Medicare Advantage (MA) risk score calculation, health plans will begin to receive “data exchange reports” from CMS comparing encounters data records (EDR) and chart review records (CRR) from the Integrated Data Repository (IDR) to audited HEDIS submissions and Patient Level Detail (PLD) files.

Through these reports, CMS provides a list of identified issues related to anything from encounter data field errors to HEDIS measure numerator discrepancies, and they request the following:

An explanation for detected issues,
A description of any action that is planned or in progress to prevent further issues of this kind, and
Information about whether corrected or missing encounter records will be submitted.

What Does This Mean for You?

If the identified data issues are valid, then your risk scores may be inaccurate. Inaccurate risk scores could lead to lower financial reimbursement and greater compliance risk.

Additionally, identifying and resolving data quality issues related to both the EDS submission and HEDIS data takes a cross-functional team who have the expertise in both risk adjustment and HEDIS. In most cases, risk adjustment and HEDIS reporting are operated as separate units and are not mutually exclusive. Navigating each area while trying to detect potential data issues can be a difficult task.

Meeting Your Audit Needs:

Attest’s unique position as a NCQA Licensed Organization with auditing experience in HEDIS as well as risk adjustment will allow us to work with your heath plan to identify and resolve the issues identified by CMS. Our Certified HEDIS Compliance Auditors (CHCAs) have a detailed understanding of the complex web of systems, processes, and data transfers; and we can use that knowledge to help you to determine the root cause and help your organization create an action plan to remediate the issues identified by CMS.