This is the first of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. Upcoming posts will focus on reducing encounter submission cost and complexity; and ensuring continuous compliance.

Ensuring revenue integrity

Industry experts estimate the number of Medicare Advantage plans has increased by 34 percent in the past 24 months. While not as prolific, managed Medicaid plan options also continue to grow (crucial for those members in states where individuals can select their own plans). These stats reflect a buyer’s market, which means there is plenty of opportunity for both traditional, established health plans and newer, smaller, and provider-owned plans, looking to participate in a rapidly expanding market.

But it’s not all rainbows and puppies. The possibility for revenue loss, and for those losses to occur quickly, is very real. Managed care plans only get reimbursed by the state/CMS for the encounter files they submit accurately, completely, and on time. This means managed care plans must submit encounter files completely (especially all HCC codes), accurately and on time (including all sweeps periods). They must also be able to easily reconcile responses files from government agencies and prioritize exceptions for correction and resubmittal to ensure comprehensive revenue integrity.

That said, not all encounter submission systems are created equal. Regardless of the chosen direction (vendor-supplied, internal build, or a combination), there are a handful of non-negotiable capabilities that every line of business (Medicare Advantage, managed Medicaid and Marketplace-participating plans) must have within their encounter management solution to ensure revenue integrity. Those capabilities are:

  • End-to-end lifecycle user interface (UI) visibility with dynamic dashboards to provide enhanced tracking
  • Prioritized exception management workflows to ensure accurate risk adjustment scoring
  • Upfront data validations to improve first-pass rates

With these capabilities in hand, managed care plans of all flavors and sizes can put themselves in a position to ensure accurate risk-adjusted revenue. Without these capabilities managed care plans can find themselves struggling to ensure revenue accuracy, struggling to provide the desired care quality, and struggling to drive member satisfaction.

Don’t be one of these plans. Do be one that leverages a comprehensive evaluation guide in selecting an encounter management system.

An evaluation guide can help ensure the selection of the best encounter submission system for your plan. A definitive evaluation guide is invaluableregardless of whether you have an existing system and are simply looking to evaluate its capabilities, are putting together an RFP for your next system, or are in the middle of an RFP response period and need guidance on how to make the right choice. Edifecs has already done the work for you.

Upcoming posts will focus on reducing encounter submission cost and complexity; and ensuring continuous compliance. If you need additional insight now, click here to review the Definitive Guide for Encounter Platform Selection Success.