This is the final article of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. This post focuses on how to ensure continuous compliance.

So far in this three-part series, we’ve covered the requirements for driving risk-adjusted revenue integrity and reducing encounter submission cost and complexity. Our final installment focuses on how to ensure continuous submission compliance amid constant changes on both the state and federal sides of the equation.

Compliance can take many shapes. Most often, we find out customers need to comply with specific data formats in a required timeframe. Failing to adhere to either of these requirements results in financial penalties from the state for managed Medicaid or a disruption in the recoupment of risk-adjusted revenue from the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage.

Managed care plans that use more than one encounter management system frequently incur these penalities. Often managed Medicaid plans that operate in more than one state run a separate system on a per-state basis. Medicare Advantage plans regularly use one system for Risk Adjustment Processing System (RAPS) and one for Encounter Data Processing System (EDPS). Payers that participate in both programs often operate what could only be described as a “plethora” of encounter submission and reconciliation systems. Both scenarios translate into a compliance (and possibly revenue) nightmare. The situation is exponentially exacerbated when the state or CMS makes changes to submission rules/regulations. This requires many organizations to make changes to multiple, highly-customized encounter management systems—a time consuming and costly process.

Winning the continuous compliance game begins with the use of a single, flexible (and in the case of managed Medicaid plans, state-specific) encounter lifecycle management system. This solution must:

  • Ensure adherence to state/CMS guidelines
  • Be “in the know” (as in constantly monitoring CMS and the states for upcoming changes)
  • Drive compliance with HIPAA standard guidelines

With these capabilities, managed care plans can avoid the pitfalls of non-compliance, avoid penalties, and reduce risk-adjusted revenue hiccups. Managed care plans are also well-positioned to efficiently execute on strategic expansion plans. When compliance in existing markets is a massive struggle, payers are more reluctant to move into new markets or lines of business. This can also have a direct line impact on their ability to compete effectively against new and existing competitors. Don’t be one of those health plans.

Be a health plan that uses a comprehensive definitive guide for selecting a best-in-class encounter management system. Regardless of whether you are a managed care plan that is considering putting out an RFP, is in mid-RFP response cycle, or simply is a plan that wants to evaluate its current system, a comprehensive evaluation guide will prove invaluable. Remember, the cost of making the wrong choice can be devastating.

Did you miss the first two installments in this series? You can find them below:

If you are ready for the Definitive Guide to Encounter Platform Selection Success, please click here.