Qualified Patient Encounters

You may be hearing stuff about how Medicare Advantage is transitioning from something called “RAPS” to something else called an “EDS” for risk code collection—and how it’s going to devastate your cash flow.

 

 

Don’t worry about it.

 

 

Those acronyms simply refer to different sets of patient encounters from which data is pulled for data-based payment.

 

 

Medicare believes one set will create a more accurate representation of a patient’s disease burden and insurers believe the opposite—and that any changes will cut their revenue.

 

 

For all but the top-level strategic planners, you don’t need to know the details.

 

 

You need to keep your eye on the ball.

 

 

 

All you need to know is that under either system, risk diagnoses will still only be able to be submitted as the result of a “qualified patient encounter.”

 

 

 

“Qualified patient encounters,” for your purposes, are face-to-face visits between the patient and the clinician in the setting of a hospital—as either an inpatient or observation stay, or in the ER, nursing home, office, residential care center, rest home or (under specific circumstances) a house call.

 

 

 

Not the phone, not via telehealth (not yet at any rate), not via email.

 

 

 

Not by DME providers or radiography reports.

 

 

 

Not by therapists

 

 

 

Only the face-to-face encounters above count.

 

 

 

That’s all you need to know.

 

 

Now act on that knowledge

 

 

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