Affordable Care Act (ACA) plans often struggle with incomplete, delayed, or inconsistent encounter data from providers, which complicates accurate member cost tracking, quality reporting, and regulatory submissions. These challenges are compounded by tight CMS deadlines and heightened scrutiny, requiring plans to reconcile encounters with claims while achieving data accuracy for risk adjustment and compliance.
A health insurer serving several million lives across regional and national markets faced evolving regulatory requirements and changes in member risk profiles, increasing the importance of accurate submissions and risk adjustment. It needed to adapt quickly to CMS encounter submission guidelines while improving internal processes for data quality, error handling, and resubmission prioritization.
Key obstacles included:
- Limited expertise in the “Three R’s” (reinsurance, risk adjustment, and risk corridors)
- Insufficient familiarity with CMS business rules
- High rejection rates
- Limited tools to track and resolve exceptions
Operationally, the plan also needed more efficient ways to manage interim bills and local charges, improve risk score accuracy, and handle claim adjustments, retriggers, and orphan-claim checks.
Implementing and configuring Encounter Management
After extensive evaluation and validation, the health plan selected Encounter Management based on alignment with business and technical requirements, cross-market support across managed care lines of business, and positive references from other Encounter Management clients.
Encounter Management’s out-of-the-box capabilities emphasized configurable front-end edits via business rules, streamlined error correction and exception handling, and tracking/reporting to improve visibility into ACA-related activities. By aligning with applicable CMS submission guidelines, the platform helps teams identify data issues early and hold submissions until corrections are made.
Following go-live, the plan continued to collaborate on usability and compliance-driven enhancements, including more intuitive dashboards, improved exception handling, and additional business rules to reduce the likelihood of CMS rejections.
Achieving short- and long-term success
The organization saw rapid operational improvements after go-live, including better visibility into CMS edits, clearer prioritization of errors, and a more streamlined resubmission workflow. Automation and a more visible exception process reduced manual effort and supported efforts to improve revenue integrity related to risk adjustment.
Over more than seven years of working with Encounter Management, the plan has sustained strong submission performance. Over the last three years, its average acceptance rate for EDGE members reached 99.93% while average acceptance for EDGE claims reached 99.74%, consistent with outcomes reported by other Encounter Management users.
We continue to work together with the health plan to support evolving CMS requirements and operational needs.
Key results*
- 99.93% average acceptance rate for EDGE members over the last three years
- 99.74% average acceptance rate for EDGE claims over the last three years
- Improved visibility and control of submissions, including clearer insight into CMS edits and better prioritization of errors
- More efficient resubmission operations, with increased automation and a clearer exception process
Key solution benefits
- Higher encounter pass/acceptance rates, helping identify and fix encounter-data issues before sending to CMS
- Better exception handling and prioritization to quickly prioritize errors for resubmission
- Reduced manual effort and support for compliance readiness efforts with automated and streamlined workflows
Key differentiators
- 51% of all EDGE encounters submitted to CMS are generated by Encounter Management
- Aligning with CMS submission guidelines to identify issues and hold submissions until corrected, avoiding rejections
- An automated, highly visible exception process that helps streamline and prioritize errors for resubmission
*The results depicted are based on an individual client’s experiences and circumstances. Results may vary depending on factors including but not limited to usage and application.
Interested in learning more? Discover how Encounter Management can help your health organization with operational efficiency, support submission accuracy, and strengthen compliance.
