Risk Adjustment Payment & Identifying Discrepancies (RAPID)
In the Affordable Care Act (ACA) zero-sum risk-adjusted environment, it is critical for organizations to make sure they are identifying and fixing EDGE data deficiencies. Since the start of the ACA program, Wakely has been helping carriers review and analyze their EDGE data to ensure they are not losing revenue due to fixable EDGE data submission errors. Ignoring data issues can lead to millions in lost revenue in the small group and individual markets.
RAPID is Wakely’s proprietary tool that replicates the “black box” EDGE calculations in order to identify submission issues that may impact your financial results. The RAPID tool prioritizes rejected or orphaned claim identifiers that may improve financial results for your risk adjustment and high-cost risk pooling claimants. Highlights include:
- Prioritization of rejected and orphaned medical and pharmacy claims that, if fixed, would add a new Hierarchical Condition Category (HCC) or additional high-cost risk pooling to a member
- Independent verification of CMS’ risk adjustment calculation at the member and condition level
- Identification of systematic EDGE issues by comparing key metrics to benchmarks
- CMS qualitative outlier metrics
- Calculation of the impact of supplemental submission (e.g. impact on the risk transfer from add and/or delete codes) and list of ineffective supplemental encounters
- Mother-Infant bundled claims identification
- Diagnosis code truncation & provider coding patterns
- Monitoring of telehealth claims and conditions related to risk adjustment
- Other diagnostics & benchmarks based on millions of ACA lives
RAPID Analytics, Rapid Results
Fixing issues on the EDGE server is a race against competing deadlines and priorities. RAPID not only prioritizes which issues your team should focus on, it helps you do it quickly: the analytics package is developed up to four times for a benefit year with a very fast turnaround. RAPID uses the standardized set of inbound and outbound EDGE XML files. Once Wakely receives your complete set of files, results are returned between three to six business days. Our team works hard to provide timely results for your EDGE team to review.
The RAPID tool creates straightforward risk adjustment and submission analytics for review by your team. With each report, our experts will guide your team in identifying actionable insights from the results. The report focuses on metrics and analytics that have proven the most impactful over the past 7 years of EDGE data review for our clients.
Each year the report is improved to incorporate any changing aspects of the risk adjustment model. For the 2018 benefit year risk adjustment analysis related to pharmacy claims and RXCs were integrated into our claim prioritization and benchmark reporting. The federal high cost risk pool and state based reinsurance programs were are also included in the RAPID tool in 2018. The 2021 version of RAPID incorporates the recent changes to the risk adjustment model that include new HCCs for the first time since 2018.
Timelines
EDGE data submissions follow the schedule outlined by CMS; however, each submitter’s needs change throughout the year as issues are identified and fixes are scheduled. Our team will work with yours to schedule RAPID reporting runs to provide the greatest impact to your EDGE team in the review of your submission. A sample schedule is outlined below:
Additional Analytics
The RAPID platform allows for flexibility to assist issuers with more advanced analytical problems. There are two primary add-on services to RAPID:
- EDW Add-On: Our enterprise data warehouse (EDW) add-on assists issuers in making a direct comparison between their EDGE submission and internal database. This process requires a more in-depth data collection to allow Wakely to compare the EDGE data to your claims and enrollment extract from your EDW. The add-on analytics will assist your team in identifying encounters existing in your internal database that are not being accounted for in the EDGE server.
- Supplemental Add-On: Wakely has developed advanced analytics to quantify the financial impact of supplemental efforts (diagnosis code submission, home visits, etc.). Wakely’s approach can isolate each effort to help provide an accurate calculation of each program’s impact on the final transfer amounts. In most cases an additional data pull will be necessary for Wakely to conduct this work.
Every health plan’s needs are unique. If you would like to better understand RAPID analytics and how they can assist your EDGE data preparation, please contact our team to schedule a demonstration.
