Risk Adjustment Accuracy: Claims to EDPS and RAPS Comparison

Client Challenge:

Cirdan’s client, a Health Plan with a Medicare Advantage Contract, had a significant gap between their EDPS and RAPS generated risk scores. With the increased weight on encounter data risk scores, the client knew a significant portion of their revenue was at risk for future years.

Our Solution:

• Cirdan compared claims data to the client’s EDPS and RAPS data and identified:
  • Claims that were not submitted in EDPS
  • Differences between HCCs included in RAPS but not EDPS data
• Cirdan estimated the revenue associated with the differences to illustrate the substantial impact the poor quality encounter data had on the client’s current and future revenue

The Result:

The client was able to significantly close the gap between their EDPS and RAPS generated risk scores to ensure their revenue was appropriately aligned to their risk. Today, their encounter data risk scores are comparable to their RAPS data. If their encounter data quality had not improved, the plan would have lost over 2% of their revenue under the 25% EDPS weight. In a world where EDPS is the single source for risk scores, their revenue would have decreased approximately 9%.