Ensuring accuracy and compliance can be challenging for any health plan, but is especially so for managed care organizations (MCOs) due to the complexity and fragmentation of the encounter data lifecycle. Encounter submissions must align precisely with evolving state and federal requirements, while also reflecting accurate diagnosis coding, service detail, and provider attribution to support risk adjustment. Data often flows from multiple provider systems with varying levels of completeness, timeliness, and coding consistency, which can come with an increased likelihood of errors, rejections, or retroactive corrections.
Additionally, frequent regulatory updates, inconsistent state-specific validation rules, and strict submission timelines place operational strain on MCOs, making it difficult to balance accuracy, compliance, and speed without robust governance, analytics, and controls.
For years, one MCO with two million members serviced multiple lines of business (including Medicare, Medicaid, and the ACA Marketplace) faced significant challenges without an encounter solution. The plan had a backlog of rejected encounters potentially worth over $500 million and was struggling with compliance for state and federal encounter metrics.
The plan needed a solution that would streamline its encounter operations and make it easier to:
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Configure data to align with market-specific requirements
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Maximize encounter submission accuracy and first-pass rates
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Apply modifications and custom rules
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Support ongoing compliance with evolving CMS and state guidelines
The plan ultimately decided to choose Encounter Management for its comprehensive encounter lifecycle management platform and its prebuilt knowledge packs.
The knowledge packs reflect compliance needs for 40 states' State Medicaid agencies which impose highly nuanced and frequently changing encounter submission regulations, including state-specific data elements, file formats, validation rules, timeliness thresholds, and resubmission workflows. Failure to comply can result in significant consequences, and can sometimes directly impact risk adjusted payments or result in withholds that are only released once data quality thresholds are met.
By embedding state-specific regulatory intelligence directly into the submission process, Encounter Management helped the MCO proactively manage compliance risk, reduce rework, and protect revenue while maintaining confidence in their standing with state regulators.
Results and moving forward
Since implementing Encounter Management, almost all previously manual work performed by the client has moved into the solution with overwhelmingly positive results.*
Maintaining compliance with CMS and state-specific guidelines no longer requires extensive manual monitoring. As the data show, the plan has continued to meet its internal SLAs for completeness, timeliness, and accuracy:
| KPIs for Encounter Submissions | 2024 DOS | 2025 DOS |
|---|---|---|
|
Medicare Advantage Acceptance Rate |
99.50% |
98.50% |
|
Medicare Advantage First Pass Rate |
99.50% |
96.20% |
|
Medicaid Acceptance Rate |
97.98% |
98.43% |
|
Medicaid First Pass Rate |
97.36% |
97.12% |
|
ACA Medical Acceptance Rate |
99.97% |
99.93% |
|
ACA Member Acceptance Rate |
99.99% |
99.98% |
The MCO attributes the plan’s positive experience with Encounter Management to the quality of the solution and the team supporting it. "The SMEs are really knowledgeable,” the client said. “Unlike other IT teams, we don’t have to spoon-feed them the business terms and details—they understand the business context.”
The plan intends next to build on the successful implementation of Encounter Management by taking advantage of the solution’s AI-enabled exception management workflows.
Key solution benefits
- Increased submission accuracy and first-pass rates across Medicare, Medicaid, and ACA, improving data quality and revenue reliability
- Optimized encounter workflows, reducing manual effort and enabling scalable, efficient operations
- Supports simplified, sustainable compliance with CMS and state requirements without resource-intensive monitoring
Key differentiators
- Prebuilt state and regulatory intelligence to accelerate compliance
- Expert-led delivery with deep healthcare domain knowledge
- End-to-end orchestration across the encounter lifecycle
Interested in learning more? Discover how Encounter Management can help your health organization with operational efficiency, support submission accuracy, and strengthen compliance.
*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.
