On February 21, 2024, the Center for Medicare and Medicaid Services (CMS) released a notice detailing the requirements for Medicare Advantage (MA) Organizations (MAOs) to submit supplemental benefit encounter data through the Encounter Data Processing System (EDS) beginning with 2024 dates of service.
EDS submissions are predominantly managed by risk adjustment programs, either internally or by an external vendor partner. EDS is the single source of information used by CMS to calculate risk scores and the initial, mid- and final-year payments to MAOs. This highly technical process requires dedication and a near 100% outcome to ensure the completeness and accuracy of CMS financial payments.
Introducing supplemental benefit data, which will not impact risk scores or financial payments, adds a complicating factor to an already complex process for MAOs.
No system of record for supplemental benefits
Most EDS submissions are encounter data processed through MAO claims systems, providing a system of record to reconcile inbound submission counts and response files.
Most supplemental benefit transactions do not generate a claim, as they are not reimbursed in the same ways as traditional medical claims. This results in no single source of record for EDS submitters to use for quality assurance.
Let’s set aside dental, which has its own submission format and process. External vendors manage most supplemental benefits (such as OTC, healthy food and grocery, transportation, and utilities) and typically provide remittance reporting only periodically. Though some MAOs struggle to even get that much information.
Documenting the end-to-end data flow of information and the needed controls to ensure accuracy and compliance is a necessary exercise for every MAO to perform.
This is going to be complicated
CMS has stated that transaction-level and aggregated summaries by members are acceptable, depending on the benefit. Some supplemental benefits, like fitness memberships, do not generate transactional level data rather, the quarterly benefit amount provided, and the amount spent by the member. Further, there are no CPT codes, revenue codes, ICD-10 diagnosis codes, etc. so CMS has provided technical specifications for MAOs to map data to generate an acceptable 837 record for submission.
With some supplemental benefits being submitted at the transactional level, and others aggregated, an established quality assurance and control process is paramount.
Determine the aggregator and owner of supplemental benefit data
Many supplemental benefit providers are not familiar with CMS Medicare regulations and/or complex healthcare data, as many started in other markets and evolved their businesses when CMS expanded supplemental benefits a few years ago. Furthermore, many MAOs rely on fintech organizations, not healthcare organizations, to manage the transactions of many of these benefits with restricted payment cards—although not all supplemental benefits are managed on a single payment card.
Between the MAO, multiple supplemental benefit vendors, flex card vendors, and external EDS submission vendors, MAOs need to develop their strategy and processes for:
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- aggregating all disparate supplemental benefit data,
- establishing their submission processes, and
- ensuring the necessary oversight and controls.
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Don’t panic, we have time
The deadline for 2024 dates of service submissions is January 31, 2026. MAOs should make meaningful progress on submissions in advance and should be accelerating their strategy and processes.
Let us help you align your supplemental benefit data and encounter submissions
Convey is a proven Medicare partner to leading MAOs across the country with over 15 years of experience serving MAOs. Further, through our analytic division, Pareto Intelligence, we are experts in Medicare risk adjustment and the complexity of EDS submissions.
