Legacy encounter submission processes are a continual challenge within the healthcare continuum. Slow, opaque, and difficult to correct, issues with outdated technology present difficulties, especially in light of the increasing need for speed and scale in healthcare technology.
A nonprofit health insurer in the Northeast needed timely, accurate encounter submissions to support operational performance and applicable regulatory requirements. Its prior vendor solution provided limited visibility and delayed feedback, making it difficult to identify and resolve errors quickly. Challenges included limited edit capabilities, operational inefficiency, incomplete data and limited data view, and processing delays.
After an audit later uncovered processing issues that resulted in approximately $40M in encounter data not being submitted, the plan initiated a search for a more transparent, proactive solution to improve data congruence and integrity.
Implementing Encounter Management
The plan expanded its existing vendor relationship and selected Encounter Management based on prior success with adjacent solutions and the need for stronger encounter expertise and transparency.
In implementing the solution, the client expressed a desire for more in-depth guidance. During implementation, the client received deep technical expertise, consistent support, and hands-on collaboration to help deliver a smooth transition. The implementation team helped provide assets, team calls, and more to help them understand the process and make adjustments as necessary. As the client summarized, “This was one of the best implementations I’ve seen in my time in the risk adjustment space.”
Achieving lasting results
“With Encounter Management, we send a file, and we know what the impact is in real time,” the client said. “We don’t have to wait for the MAO-004s—we are able to track and fix errors and missing codes as soon as possible.”
Following implementation, the plan began realizing meaningful benefits from Encounter Management almost immediately. Upgrading from the data loss and persistent quality issues that plagued its legacy system, the plan gained a secure, unified source of encounter data that improved accuracy and reliability across submissions. Encounter data from multiple sources—including coding teams, NLP solutions, retrospective reviews, and third-party chart retrieval vendors—flows into a single, integrated platform, significantly reducing errors and rework. This end-to-end automation and interoperability has streamlined operations behind the scenes, improved data integrity, and reduced the operational burden associated with preparing and managing submission files.
The plan also experienced significant efficiency gains through faster error identification and correction, with real-time visibility into submission impacts and the ability to resolve issues—down to the line level—before final submission. This shift has resulted in consistently high acceptance rates, reported at 98–99%, while saving both time and administrative cost. Seamless integration with Retrospective Reviews further simplified medical record retrieval, enabling the plan to review more data, identify incremental revenue opportunities, and achieve meaningful economies of scale.
With better insights into coding gaps and encounter performance, the plan is now able to collaborate more effectively with provider partners, supporting improvements in RAF scores and strengthening relationships through greater transparency and trust. As the customer described it, transitioning from their legacy solution to Encounter Management was “like going from a bicycle to a Ferrari.”
Key results*
- 98–99% reported encounter acceptance rate post-implementation
- Near real-time visibility into submission impact to prioritize high-value fixes
- Line-level corrections enabled, reducing full-file resubmissions and rework
- Improved data integrity and reduced risk of data loss compared with the legacy process
Key solution benefits
- Greater transparency and control over encounter submission and correction workflows
- Reduced operational burden through automation and faster feedback cycles
- Improved compliance readiness supported by enhanced data completeness and integrity
Key differentiators
- Proven encounter submission expertise and implementation support
- Configurable edits and validation to address errors earlier in the process
- Unified platform approach to integrate encounter, review, and retrieval workflows
*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.
Looking to learn more about how to avoid unresolved errors and improve data? Discover how to close gaps with near real-time visibility with Cotiviti’s Encounter Management solution. Read the fact sheet to learn more.
