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BLOG. 2 min read

Time to Commit to Reconciliation of Your Encounter Data Submissions

Your health plan’s encounter submission processes are in place with files getting submitted like clockwork, so you can sit back and relax, right? 

No! More than 80% of revenue for a typical Medicare Advantage (MA) health plan is risk-adjusted revenue, and if you aren’t continuously evaluating and reconciling encounter submission and response files, you could be missing out on millions of dollars in annual revenue.

A study was discussed in the Milliman white paper, Medicare Advantage’s transition from RAPS to EDS risk scores: 2017 impact1 that found EDS risk scores to be approximately 2.5% lower than RAPS risk scores. Closing this gap is important as MA revenue becomes more dependent on EDS-based scores. These findings also illustrate the importance of making sure EDS submissions are successful.

CMS, HHS, and Medicaid data management reports include submission response files that provide the status (i.e., success) of your submissions. This includes which records were accepted, which were rejected and the reasons why. A successful encounter submission program requires multiple levels of reconciliation so you can maximize your accepted submissions the first time.

For a Medicare Advantage plan, we recommend reconciliation, data validation and controls be conducted to maximize encounter submission data integrity, which will result in more accurate revenue payment to your plan. A thorough, end-to-end reconciliation process includes the following:

  • Reconcile physician claims/encounter data to extracted data to ensure all eligible claims are included for encounter submission
  • Reconcile encounter submissions to response files at an encounter level to ensure that any eligible encounters that did not get accepted in each processing step get resolved and resubmitted
    • Reconcile RAPS submission files to the RAPS Return Flat response files
    • Reconcile EDPS submission files to the 999, 277CA, and MAO-002 response files
  • Reconcile claim, supplemental and submission data routinely to identify potential leakage or operational issues
  • Reconcile risk scores and HCCs from submission data shown in the MMR and MOR to CMS reports
    • RAPS Return Flat file and EDPS MAO-002 for rejected claims (example, incorrect date of birth)
    • EDPS MAO-004 for disallowed claims and chart reviews (procedure code allowed)
  • Reconcile RAPS and EDS differences
    • Compare diagnosis codes on both
    • By percent difference, by plans, by HCC, by providers
    • Comparison against industry benchmark

I have focused on MA submissions, but Health Insurance Marketplace and Medicaid submission and response data management reports should be reconciled similarly. There can be negative financial impact due to incomplete encounter submissions for these types of health plans as well.

Reconciling your encounter submissions may also help minimize data validation risk, identify data leakage and deficiencies in back-end systems causing data to be dropped, and identify anomalies in your data that could lead to potential overpayments. These proactive activities enable your plan to take action to make timely corrections to submitted data.

Comprehensive reconciliation also allows the findings to be leveraged for other proactive plan activities such as provider education and correction of incorrect claim processing. Doing so will result in accurate claim submission, accurate claim processing, and reduced post-submission error-correction activities.

I hope you see that commitment to this level of reconciliation of your encounter submission data is well worth the time and money when you consider the potential significant financial impacts to your plan.


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