Building a scalable Encounter Management foundation for growth

For specialty care providers operating in highly regulated Medicaid and value-based care environments, encounter submissions are mission critical. Accuracy, compliance, and scalability are key factors impacting revenue, operational efficiency, and contract performance.

After struggling with an outdated, homegrown encounter solution that increased risk and slowed growth, a specialty care provider adopted Cotiviti's Encounter Management solution to modernize submissions, streamline operations, and support rapid expansion across new markets.

The challenge: Legacy technology limiting performance and growth

The organization works with leading health systems to coordinate complex care, manage chronic conditions, and support government programs across Medicaid markets. For years, encounter submissions were managed with an internally built solution.

"The development environment wasn’t stable, which was time-consuming and [added to] the total cost of ownership in many ways,” our customer told us. As regulatory complexity increased, the limitations of the homegrown approach became more pronounced. Our client needed a robust encounter submissions solution that would allow them to:

Improve operational agility
Focus more on upstream performance
More efficiently allocate technical and personnel resources
Accelerate implementation in their own markets

With government contracts at stake, the organization needed an approach to encounter submissions that would help support scalability, compliance, and efficiency.

Implementation: Partnership-driven success

After evaluating whether to rebuild internally or adopt an external platform, the organization concluded that a third party solution would be more cost effective and sustainable. The organization initially implemented Encounter Management as an on premises solution, collaborating closely with the Cotiviti team during early Affordable Care Act market expansion.

Cotiviti’s solution offered “a standard that’s industry-recognized, which would help us accelerate the implementation and compliance components compared to managing and owning everything in-house,” said the customer. “Another key consideration was the kind of market that we [operate] in, which is very regulation- and compliance-heavy, especially when it comes to encounters. You have a tried and tested platform that complements our business so we can focus on performance.”

As Medicaid membership grew year over year, the organization moved from an on-premises environment to a hybrid cloud based Encounter Management environment.

The benefits were immediate:

Reduced IT burden by eliminating hardware, maintenance, and performance monitoring
Built in scalability without the need to purchase additional infrastructure
Automated updates designed to reflect evolving regulatory requirements, reducing the need for certain manual compliance updates
Faster market rollouts, with reported reduction of implementation timelines by nearly half

The migration also allowed the organization to dramatically reduce its own implementation timeframes.

“With our homegrown solution, if we had a go-live for, say, January 1, 2025, we would have to start implementation at least nine or 10 months in advance. With Edifecs [now Cotiviti], that timeframe is reduced to four or five months,” said the customer. “And when one function is more efficient in terms of rollouts, then it [positively] influences our overall implementation timelines as well.”

Results: Measurable impact across markets*

Since adopting Encounter Management, the organization has expanded into multiple new Medicaid and commercial markets, including highly regulated and penalty heavy states.

“We couldn't have done it without having a platform like Encounter Management,” our client stated.

The solution has also become a differentiator for reference in sales conversations with health plans, provider organizations, and state agencies—demonstrating operational maturity and support for compliance readiness. Eliminating the burden of maintaining hardware and software has enabled the organization’s internal team to focus solely on monitoring encounter performance. The organization reported a 100% member acceptance rate and a 98.64% encounter acceptance rate during the measured period.

Total Unique Members Submitted	Member Acceptance %	Total Encounters Submitted	Total Unique Encounters Submitted	Encounter Acceptance %
2,271	100%	16,914	11,721	98.64%

Key benefits

Reduced internal IT workload and total cost of ownership
Faster implementation and expansion into new markets
Support for ongoing compliance efforts with automatic regulatory updates
Improved operational agility and performance focus
Demonstrated scalability to support Medicaid membership growth

Key Cotiviti differentiators

Industry recognized encounter processing approaches
Proven experience supporting compliance in regulation heavy Medicaid environments
Scalability with hybrid cloud hosting platform
Deep expertise supporting government and value based care programs
Trusted partner enabling growth, not just technology

Read our fact sheet and learn how Encounter Management provides a single, flexible encounter lifecycle platform tailored to the unique requirements of each line of business.