Experience

MODERNIZATION OF THE ENCOUNTER DATA PROCESSING SYSTEM AT THE CENTERS FOR MEDICARE AND MEDICAID

Challenge

The Centers for Medicare & Medicaid Services (CMS) implemented the Encounter Data Processing System (EDPS) to allow the agency to collect, process and analyze Medicare Advantage (MA) encounter data, which is used to calculate payments. Processing tens of millions of records weekly and hundreds of millions annually is a monumental task. Since 2004, the number of Part C beneficiaries has more than tripled and now accounts for one-third of all Medicare enrollees.

Solution

To meet Department of Health and Human Services’ strategic goal to Reform, Strengthen, and Modernize the nation’s healthcare system, CMS evaluated solutions to modernize the EDPS platform. This resulted in the agency selecting a scalable cloud infrastructure to increase processing capacity. As a result, CMS has been able to grow Medical Advantage program enrollment, while simultaneously lowering costs.

The most innovative aspect of EDPS NextGen is its proposed scalable cloud-based architecture, which can handle the accurate and timely processing of an ever-increasing volume of encounters. The system’s processing engine produces near real-time encounter results and eliminates about 25 system cycle hours per week compared to the legacy EDPS, thereby providing rapid processing and MA reporting for faster reconciliation. It accommodates changing policies and business rules for the Part C program while implementing Medicare pricing logic in an English like rules engine.

Results

In 2017 this program successfully processed more than 800 million encounters. When complete, EDPS NextGen will support near real-time processing of more than 1.5 billion encounters on an annual basis on the AWS platform. The increased timeliness, accuracy, and capacity will lead to three very important outcomes: reducing administrative costs, eliminating the burden of data reconciliation, and enabling near real-time processing and access to previously unseen MA patient health data. Additionally, the new architecture and platform allows CMS to meet the HHS strategic goal of modernizing its legacy infrastructure while accomplishing program objectives.