Progress Notes: CMS Compliance for Data Management

Progress Notes: CMS Compliance for Data Management

  • 30 Mar 0
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As we mentioned in previous missives, compliance with CMS regulations for data management is a big theme this year.  CMS provided two HPMS memos recently that are relevant to PACE organizations that wish to demonstrate compliance in an important way.  The first memo on Feb 18 refers to the requirement for PACE Organizations to return overpayments to CMS in a timely fashion (defined by the Affordable Care Act as within 60 days after the overpayment is identified).

Most overpayments are due to submitting erroneous data to CMS and the following four general categories of data submissions that have the potential to result in overpayments:

  • Risk Adjustment (Risk Adjustment Processing System (RAPS) data and encounter data)
  • Prescription Drug Event (PDE) and Direct and Indirect Remuneration (DIR)
  • Low Income Premium Subsidy (LIPS) for Employer Group Waiver Plans (EGWPs)1
  • Other

Additional information about these categories is provided in the memo.  For practical purposes in PACE Organizations (PO), the most common errors are diagnosis codes that submitted to RAPS, but are not supported by the medical record.

When a PO identifies a RAPS data error through its internal (or external) auditing and monitoring process before the final submission deadline, it must be corrected.  The process of correcting RAPS data can be daunting, depending on the systems in place at your organization.  (Contact us at Capstone if you need assistance.)   Corrections can be submitted any time prior to the final risk adjustment data submission deadline, which is generally January 31 following the payment year impacted by the diagnosis codes.

The sixty-day rule kicks in after the January 31 deadline and then the process of reporting the overpayment begins by contacting the MAPD help desk at 1-800-927-8069 or and opening a Remedy Ticket. If an organization or sponsor reports an overpayment to the help desk by email, the subject line of the email should include the phrase “Overpayment Report.”  The HPMS memo provides details about creating the Remedy Ticket and instructions for submitting the necessary RAPS data.

After your overpayment data is submitted, CMS will announce when it will rerun risk scores for prior payment years.   The payment adjustments will be processed as part of the routine MARx process and show up on the next Monthly Membership Report (MMR).   For 2015, reruns will be completed for the following prior payment years:


Payment Year


Dates of Service


2010 2009
2011 2010
2012 2011
2013 2012
2014 2013

CMS will notify plans at least 30 days in advance of the deadline for submitting deletes for each model  run.  Meanwhile, we urge all POs to carefully review their RAPS data and take advantage of this opportunity for self-correction.  CMS has indicated that, in an audit situation, they will take a more favorable disposition toward plans that self-correct vs those that don’t.

Capstone provides auditing services to assist any program with compliance in documentation and coding.  Please contact us for more information.