This is the second of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. This post will focus on how to reduce encounter submission cost and complexity.

In the first blog of this three-part series, I discussed the mission-critical encounter management components required by managed care plans to ensure revenue integrity. Let’s now turn our attention to the flip side of the financial discussion–reducing submission and reconciliation costs (and the complexity that drives those costs). For many managed care organizations, the encounter management lifecycle is fraught with disjointed manual processes, multiple systems, and a lack of visibility and workflows that result in exacerbated costs on both the IT and operational sides of the house.

Market opportunities in both Medicare Advantage and managed Medicaid are rapidly expanding. Great news, right? A plethora of new members that continue to increase, opening up new market opportunities for new and existing health plans alike. The challenge is that a majority of these plans are ill-equipped to efficiently manage the complexity of encounter submission. Medicare Advantage-participating plans frequently operate two separate encounter systems; one for Risk Adjustment Payment System (RAPS) and one for Encounter Data Processing System (EDPS). This “dual system” results in myriad manual processes, especially when it comes to response reconciliation and exception handling.

Medicaid managed care organizations (MCOs) suffer from similar challenges. States make frequent changes to their companion guides (as New York has done recently), requiring plans to make system adjustments that can be costly and consume both time and resources. Operating in more than one state? Your costs and complexity are multiplied. It is often said, “If you’ve seen one state Medicaid program, you’ve seen one state Medicaid program.” The lack of consistency and commonality in formats and other submission requirements across states makes it both difficult and expensive to operate in these markets– especially with sub-optimal, non-integrated encounter platforms.

Overcoming cost and complexity challenges requires a best-in-class encounter submission system (and possible vendor) that delivers the following:

  • A single encounter platform for all managed care lines of business
  • Embedded AI/ML technologies to enhance predictive measures and alerts
  • Hosting, consulting services, and business operation support

These capabilities ensure that plans can reduce IT and administrative costs and complexity, and open doors to market expansion. Often times, managed care plans forgo or restrict expansion planning as they simply cannot afford it. Deploying a comprehensive encounter submission and reconciliation system can catalyze new growth due to lower costs and improved efficiency. Without the capabilities I’ve discussed, managed care plans can quickly find themselves behind their competitors. Don’t be one of those plans.

Be one of those plans that leverages a comprehensive evaluation guide to ensure your current system is fully capable or that you select a vendor platform that meets all your encounter submission requirements. Part of this evaluation process includes reading the upcoming part three of our blog series that will address continuous compliance.

Did you miss Guide Post 1 on improving risk-adjusted revenue integrity? You can read it here. If you need additional insight now, click here for the Definitive Guide to Encounter Platform Selection Success.