healthcare reform, encounter data and claims

Proper Data + Reform = Payment Impact

In our last blog post we began to go over the potential impact that new ways of utilizing Encounter Data and Claims could have on healthcare reform.  Following up on that discussion we though we would share some interesting statistics that were recently released by the Office of Inspector General and CMS.

  • Currently 39 States and Washington D.C. are running Capitated Manged Care Plans
  • All 39 states with capitated Medicaid Managed Care are responsible for  the collection of Encounter Data, and the utilization of this information for purposes of rate setting, detection of fraud and abuse, and monitoring of program expenditures
  • Only 28 of these states were able to successfully submit the required data per CMS specifications, the other states experienced “significant difficulty” according to the OIG, and not all of the states submitted their data on time; in fact
  • 15 of the 40 states were unable to submit data at the time of the OIGs review

In response to these poor performance numbers the OIG is now beginning to push for monetary sanctions against states who do not adequately supply the adequate information.  Furthermore, the Affordable Care Act has authorized the withholding of federal matching funds for states that fail to properly report encounter data in a timely manner.  All of this means that plans that do not comply correctly could lose valuable revenue.

Healthcare Reform

So, what can your organization do to gauge how prepared you are for the new CMS requirements?  We have put together a quick checklist of questions that your organization should consider

1. What is the potential CMS encounter data impact on your organization?

2. Does your organization currently have any issues with data integrity or timely reporting?

3. Are you familiar with the changing regulations, and do you have a proactive plan to address potential concerns?

4. What is your current encounter data submission process?  Are there any tools or additional training that your organization will need to employ to ensure healthcare compliance?

5. What are the CMS deadlines for encounter data as it relates to your state and your organization?

BHM strongly recommends that in order to maintain profitability and mitigate the risk of lost revenue all organizations check that they are properly certified in healthcare compliance or working with an organization that is, and that they are fully aware of the changes.  Developing a strong proactive plan to address any areas of risk or need in your organization will ensure that when Jan. 2012 hits, and the new requirements go into effect, that your organization is not left out in the cold.