Why Encounters Matter

Encounter data really didn’t matter much 5 – 10 years ago…so what has changed? Health plans typically viewed encounter data as just another output from the claims payment process; that’s until the states and the federal government started using the data to determine reimbursement rates. Then came the penalty phase, where some states became creative and turned encounter submissions into a revenue stream. These states measure and penalize for qualities like timeliness, accuracy and first-time acceptance rates ($100K penalty for one file that was double zipped?).

Why are encounters so complicated?

Though encounters look and feel a lot like a claim, they often are records of the healthcare services for which health insurers pay and – in many states – the amount insurers pay to providers for those services. Encounters often require some form of enrichment to meet the specific requirements for submission.  On the easier side of the spectrum are Medicare encounters with the exact opposite being Medicaid.  Medicaid encounters are submitted based on state rules, mostly documented in companion guides (there is a bit of art here as some rules are vague and others were grandfathered without the guides being updated). State-to-state differences can include:

  1. The date a submission/resubmission (fixed transactions) must be transmitted to the state
  2. File format and inclusion/exclusion of specific data elements within the transactions
  3. Naming conventions of files/types of transactions submitted (Original, Adjustments, Replacements and Voids)
  4. Total transactions a file can contain and how it is zipped/not zipped (note penalty above)
  5. For third-party administrators (TPAs) in our audience, there’s one more layer of complexity; some of the health plan clients have their own sets of logic they want incorporated in the encounter extracts, in addition to the state and federal rules

The IT challenges

Typically encounter extraction logic was developed much like a reporting output, rather than an encounter solution capable of tracking, trending encounters and even forecasting penalty exposure.  Each time a state came back with new logic or requests, IT just added a module or modified a query in its existing collection. The encounter extracts, which were originally thought of as a one-way transmission from health plan to government entity, were not designed with the thought of integration with workflow management software and not considered one of the original metrics executive leaders tracked.

Changing the encounter experience

A great place to start is a baseline: Ask for an aggregate report by month of the acceptance rate for each encounter submission, in each state for each line of business (LOB). Let’s call this the “perceived acceptance rate.”  As IT is asked to address state mandates, we find many IT shops got creative and added logic to interrogate the encounter data and, rather than submitting transactions that they knew would get rejected, they built logic that moves encounters with issues to a hold bucket (sometimes referred to as bypass logic). So, when presented with the baseline, comparing the number of claims adjudicated to the number of encounters submitted can let you know the accuracy of your baseline report.

The next piece is all about process flow.  Create a process flow from a data extraction through encounter submission documenting the people and tools used along every step of the way.  The technology overlaid with the human capital gives a comprehensive view of the level of maturity that exists for scaling an encounter solution.

Last, enter the penalty box. Recommend developing a grid that shows the state, LOB and penalties paid in the past year. This grid helps inform where to focus resources when the solution phase kicks in.  Other flags to consider on the grid are client complaints, open or impending corrective action plans or strategic growth opportunities.

Encounters of the best kind

Ultimately, the ideal encounter solution minimizes penalties, maximizes the submission of the total number of eligible encounters and offers transparency on the status of every single eligible encounter.  The kicker? Throw in a couple of cool dashboards for tracking and reporting success.

IQVIA’s Healthcare Technology practice has expertise with encounters processing and can integrate with your team and culture to assist with encounters every step along the way. Whether you need to build, buy a solution or refine an existing encounter process, we’re here to help.

To learn more about the IQVIA’s Healthcare Technology Strategic Planning and Digital Healthcare practice, please reach out to Ted Marsh, vice president, strategic planning and digital healthcare practice.