Increasing Encounter Data Efficiency with Edifecs

To maximize revenues, health plans participating in government-sponsored plans like Medicare and Medicaid need to capture complete and accurate reimbursement for their members. And to do that, plans need to ensure they deliver the right data, on time, to CMS. Submitting encounter data—the electronic record that details the interaction between a patient and healthcare provider for the purpose of care delivery or assessing the patient’s health status—is sometimes known as the “last mile” of the encounter process. As many health plans have learned, the quality of the data transmitted to CMS during this pivotal phase can have a significant impact on reimbursement rates.

For one private not-for-profit health insurer and leading health insurance organization, capturing accurate reimbursement was crucial to their adjustment to new ACA guidelines—but the early results weren’t very promising. After some initial struggles, they decided to leverage Edifecs’ Encounter Submissions solution, and the results speak for themselves.

In this case study, we outline the challenges affecting our customer and many other health plans like it and share how Edifecs Encounter Submissions helped them overcome those challenges. Specifically, we discuss how our customer was able to:

• More effectively track & review CMS exceptions and prioritize for resubmittal
• Significantly improve encounter pass rates (including first pass rates)
• Reduce manual workflows, lower costs, and improve overall risk-adjusted revenue integrity

Download the case study and get in touch with us to learn how we can support your organization’s encounter submissions process.