Software

Encounter Complete™

An encounter data analytics platform for payers that want flexibility to handle systematic processing of error management, interpretation, and reconciliation to meet revenue goals.

 

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StreamlineEncounter Claim Data Throughout

  • Automate and validate inbound file and counterparty processing to reconcile data that requires significant transformation to meet complex and varying file requirements for different claim types.

  • Analyze error mix and processing results to prioritize errors by using multiple filter and group-by options to help meet rigid error correction deadlines.

  • Facilitate and streamline the transition from Risk Adjustment Payment System (RAPS) processes for Medicare Advantage risk adjustment to the Encounter Data Processing System (EDPS).
  • Manage duplicate claim data by systematically replacing historical, identical claim data, and actively processing the current version to minimize multiple submissions of the same claim.

  • Minimize interruptions and rework by leveraging expert custom analytics support from our proactive, throughput focused Program Management team that helps you navigate ambiguous guidelines.

  • Reduce inaccurate submissions through our pre-submission gate validation analytics and insights to identify errors, directing resolution through clear and logical gates.

Empowering Encounter Claim Data Processing Tools and Expertise

  • Industry leading design

    • Depend on our team, experienced in CMS duals and MMP submissions, and among the first certified EDPS vendors submitting encounter data to Medicaid, Medicare, and ACA since 2000 for more than 4 million lives.
    • Allow us to navigate ambiguous guidelines to minimize client interruptions and rework through regular interaction with CMS and states.
    • Utilize our program management expertise and data implementation services focused on submission quality and volume.

  • Encounter claim data processing dashboard

    • Enable operations to quickly confirm that monthly file sets were received, successfully processed, and error rates are within expectations.
    • Gain a clear understanding of gate error, accepted, and rejected rates with risk adjustment opportunity insights to direct your activities and help ensure you meet the 95% accuracy CMS requirement, helping to increase payouts.
    • Help reduce inaccurate submissions with proprietary pre-submission gate validation analytics and insights.

  • Error management workflow

    • Review the information needed to prioritize correction efforts to maximize resources to help contribute to highest risk adjustment impact with the Error-mix List, showing the errors impacting claims and the associated potential risk value.
    • Allow your team to understand progress on specific error codes with error correction statistics and a summary view scorecard of error status and associated claims, helping users monitor error remediation.
    • Manage error correction and re-submission for top error-mix opportunities through systematic plan remediation efforts.

  • Duplicate claim submission logic

    • Overcome duplicate submission challenges with Encounter Complete logic by submitting replacement claims for claims that are voided and not accepted.
    • Reconcile split claim lines submitted with the same information on both lines by systematic aggregation of all claim services into encounter lines according to defined counterparty service duplication rules.
    • Replace historical versions of a claim and actively process the current version by accepting and linking unique claim ID mnemonics or patterns through process methodology.

Our outcomes

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Case Study

Chart Recoding and Reprocessing Yields Substantial Gain

Case Study

Chart Recoding and Reprocessing Yields Substantial Gain

Learn how an AI-driven review of a health plan’s Medicare Advantage claims produced an annualized gain of $357,000

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Video

Optimizing Risk Analytics with a Data Integration Cloud

Video

Optimizing Risk Analytics with a Data Integration Cloud

Learn how our Integrated Delivery Platform aggregates data from disparate systems to: Optimize risk analytics, Ease compliance with CMS mandates, and more.

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On-demand Webinar

Convergence of Risk, Quality & VBC: A Focus on Medicaid

On-demand Webinar

Convergence of Risk, Quality & VBC: A Focus on Medicaid

Watch this AHIP webinar to discover best practices for integrating risk, quality, and value-based care to improve outcomes and manage costs for Medicaid enrollees.

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