Staying Ahead of CMS Policy Changes – One Solution At A Time

By Abhinav Aggarwal, Sr. Director, Encounter Submission and Risk Adjustment Solutions, Edifecs
Twitter: @edifecs

Payers and health organizations struggle to manage the sheer volume of encounter data submissions due to limited visibility into the encounter lifecycle. When an organization lacks visibility into the encounter management process, inaccuracies stemming from a sub-optimal claims process can manifest. Business users want to manage all parts of the encounter lifecycle including file level tracking, lifecycle monitoring and reject management, ideally from a single source.

Disparate systems lead to inefficiencies and create unnecessary capital expense associated with managing business operations. Not to mention inaccurate data. Encounter errors can vary across all lines of business and not correcting them can lead to expensive penalties.

Additionally, keeping up with all the state and CMS proposed rulings on documenting requirements, determining the impacts, development, testing, and roll out to production can be difficult. Any misses on the interpretation or being late can impact a health plan’s bottom line. Successes, however, position health plans and organizations as the industry standard.

North American Medical Management California, Inc. (NAMM California), a collaborative management services organization that develops and manages provider networks, which represents more than 800 primary care physicians and 2,000 specialists in Southern California has adopted an innovative encounter management technology that ensures data accuracy. NAMM California is setting a new standard for the industry to follow.

Initially, NAMM California was challenged to manage and scale a large volume of encounter management data submissions. The organization had limited visibility into the entire encounter management process including, validating and generating compliant outbound encounters to trading partners and loading response files to accurately understand the final disposition of the encounter. An added complexity was managing the different submission and reconciliation format requirements for 16 different health plan clients.

With CMS’ proposed rules lighting a fire for a quick change, NAMM California invested in a new encounter management process which has produced higher encounter acceptance rates and ensured revenue integrity. Changes in its technology infrastructure resulted in single-click dashboards that provide end-to-end visibility for managing and monitoring large volumes of data, a reliable system for sending good data and identifying and holding back bad data, and multiple new custom formats for downstream health partners.

NAMM California has been able to share cleaner encounter data with its trading partners, resulting in significantly fewer rejections. Not only has the organization increased first pass acceptance rates but has been able to submit millions of transactions and increase the overall acceptance rate to 92% and over.

The countdown to CMS’ rule changes has begun, and NAMM California is proof that by investing in the right technology and the best team of encounter management experts – encounter data can be effectively streamlined and analyzed. Healthcare organizations have an opportunity to learn from NAMM California’s playbook to avoid heavy financial fines and penalties that may come with CMS’ policy changes.