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As the Encounter Data Governance Entity (EDGE), IHA is coordinating a statewide effort to improve encounter data. Through a multi-pronged approach, including technical assistance, performance measurement, industry engagement, and communication efforts, we’re aligning the healthcare community around a shared goal: to ensure that all future reporting dependent on encounter data reflects actual provider and health plan performance and an unbiased understanding of population health needs.
As a contingency of Centene’s acquisition of Health Net, the California Department of Managed Health Care (DMHC) required Health Net to invest $50 million in improving encounter data submissions in California, with a focus on Managed Medi-Cal providers. Health Net launched its Encounter Data Improvement Program (EDIP) in 2015 through a series of grants. In 2019, Health Net oversaw an industry listening process led by Manatt Health. This listening process highlighted the need for a Governance Entity to steward cross-industry alignment. Through a competitive RFP process, Health Net selected IHA as the Governance Entity in March 2021 with the charter of overseeing a multi-year, cross-industry effort to improve the completeness and reliability of encounter data in California.
IHA’s role as the Encounter Data Governance Entity (EDGE) is funded by Health Net, Inc as part of the California Department of Managed Health Care’s undertakings for Centene Corporation’s acquisition of Health Net. IHA’s work as the Encounter Data Governance Entity is governed through a milestones-based contract with Health Net, Inc.
Encounter data across California’s healthcare delivery system is fragmented and inconsistent due to the complexity, administrative burden, and a lack of standardization in how the data is submitted and processed. As a result, data gaps, rejections, and duplications threaten the reliability of the many reports and processes that are dependent on encounter data.
The main issues with encounter data in California include the following:
Encounter data issues are complicated and impact everyone from patients and individual providers to federal agencies. This is the reason IHA is coordinating efforts across California to improve encounter data.
While this problem is particularly acute in California due to the prevalence of managed care and capitation payment arrangements in the state, encounter data management is a challenge for the healthcare system nationwide, especially as more stakeholders adopt or expand population-based alternative payment models.
To pull off a statewide encounter data improvement effort, we’re working with leading organizations in provider technical assistance, industry collaboration, and those who manage encounter data for their programs. This includes California Medical Association, California Primary Care Association, the Department of Health Care Services, the Department of Managed Health Care, and Health Industry Collaboration Effort.
Learn more about the organizations taking part in this effort.
Our work as EDGE has a strong focus on Medi-Cal. However, we seek to implement industry-wide advancements across all product lines and geographies. This is because the challenges associated with poor quality and missing encounter data are not limited to Medi-Cal, and many of the stakeholders that submit and process this data operate across multiple lines of business.
According to the Centers for Medicare and Medicaid Services, encounter data is “detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.” A “capitated managed care entity” refers to providers and health plans who receive a per-member-per-month capitated rate to care for an assigned patient population.
Encounter data is detailed data which generally includes the following.
Additionally, there are several standard electronic transmission formats such as Accredited Standards Committee (ASC) X12 837 (institutional), and X12 837P (professional) that are used to submit encounter data from providers to Managed Care Plans (MCPs) and from MCP’s to the Department of Health Care Services.
If you work at a physician practice and would like to know how you impact encounter data, check out the role-based Encounter Data Impact Guide.
Many important healthcare processes rely on encounter data, including:
The encounter dataflow is the path encounter data takes from when it’s generated at the patient-provider level through its submission to a clearinghouse or to an IPA/PPG or straight to the health plan:
Patient services administered in provider practices are documented in the EHR, translated into an encounter, and directly submitted to an IPA/PPG or through a clearinghouse before being sent to an IPA/PPG. Encounters may be directly submitted to a contracted health plan as well. IPAs/PPGs aggregate and submit encounter files to contracted health plans and or managed care organizations (MCOs).
If you would like to learn more about encounter dataflow, please check out CPCA’s video Encounter Data Made Easy (at 3:42).
Claims data derives from documentation that is supplied by providers and other healthcare professionals during an encounter with a patient for healthcare services. This documentation is then translated into medical coding and applied to an appropriate claim form. This becomes the bill submitted for a patient’s care. Claims data is typically generated by providers who are billing for services provided to a patient. Fee-for-service is most commonly associated with claims.
Encounter data is also based on medical record documentation and data elements that would also be on claims forms. However, it is not tied to a specific claim for services or bill submitted for a patient’s care as the health plan has already reimbursed for services under some form of capitated contract with the provider. Encounter data is typically generated by capitated providers and submitted as a requirement by their health plan contracts.
Although these definitions are broad, the types of basic information a provider would submit for claims or encounters under other payer types (such as commercial HMO, PPO, or Medicare Advantage) is similar. However, each contracted health plan may have different requirements. It’s important to know your contracts and what is required by each.
A managed care organization (MCO) is a health plan that has agreed to participate in managed care programs and is paid a capitation rate by the state or federal government to cover all costs of a defined population. MCOs are required, under federal regulations, to collect encounter data for their defined populations from providers and healthcare organizations that are contracted with them under capitated managed care agreements. MCOs that serve Medicaid enrollees in California are referred to as Managed Care Plans (MCPs).
Health Maintenance Organizations (HMOs) typically cover care for patients only within their contracted provider networks. Preferred Provider Organizations (PPOs) typically cover more if care is received in network but may still also cover some out-of-network care.
Both HMOs and PPOs are common examples of Managed Care Organizations (MCOs).
Capitated managed care in California is most commonly seen with Medi-Cal, in which patients are assigned to MCOs by the Department of Health Care Services. MCOs then assign patients to contracted primary care providers who participate in those managed care agreements.
Many MCOs also offer commercial HMO, PPO, POS, and EPO products in addition to their Medi-Cal managed care line of business.
Medi-Cal managed care is like a commercial HMO in that patients must use only the in-network providers and Medi-Cal covers the basic benefits that all health plans cover in California. Additionally, prescription drugs, vision and hearing care are also covered. Co-pays and annual deductibles do not apply to Medi-Cal managed care. MCOs providing services to California Medi-Cal enrollees are referred to as Managed Care Plans (MCPs).
For more information on the relationship between Medicaid and managed care organizations, check out this video webinar from Center for Health Care Strategies (CHCS) (primary care focused).
Encounter data requirements may vary depending on health plans. Encounter data is typically submitted in an electronic format in accordance with state and federal regulations. Please check with your affiliated health plans for encounter data submission requirements.
According to the Medicaid Encounter Data Toolkit (2013), these are some of the most common errors when submitting Medicaid (Medi-Cal) claims:
For an introduction to encounter data, see Encounter Data 101.
There are many challenges to the submission of complete, accurate and timely encounter data:
For provider organizations that participate in IHA’s Align. Measure. Perform. (AMP) programs, please visit the Performance Reporting Portal to access your encounter data results along with the rest of your AMP performance results.
For provider organizations that do not participate in AMP, please visit your contracted health plan/IPA or PPG to access information on encounter data report cards and/or rejection feedback.
Managed Care Organizations (MCOs)/Preferred Provider Groups (PPGs): Contact your contracted health plan, IPA, or PPG.
We encourage you to visit the Encounter Data Resource Hub to access tools and frameworks for improving encounter data. At a high-level, we recommend providers improve their encounter data through the following:
If you would like to know more about how you and your staff can improve Encounter Data, check out this explainer video (at 7:14) from CPCA for providers and healthcare staff.
The Encounter Data Resource Hub offers useful tools to help train new office/billing staff, including: Info sheets, an Onboarding Toolkit (forthcoming), and an Encounter Data 101 presentation (also available for Community Health Centers). For more information on available resources and training, please visit your contracted health plan/IPA or PPG.
For Medi-Cal, fee-for-service, or straight Medi-Cal: Medi-Cal Provider Home Page.
Data standards determine and align standard sets of codes, processes, or guidelines to help ensure data consistency and usability. While instructions and formats exist for encounter data — such as various companion and policy guides from the Department of Health Care Services (DHCS), there is a need for additional defined processes, workflows, and consensus-based recommendations to improve how encounter data is collected, reported, aggregated, and analyzed.
For example, a multistakeholder workgroup can establish a standard guideline or crosswalk for translating local codes prior to submission. Such a solution would ensure that encounter data submissions aren’t inappropriately rejected or reporting doesn’t lose accuracy when aggregated across different organizations or regions. Another example of a data standard is defining modifiers and logic design for a specific coding scenario that feeds into encounter data reporting. Developing and disseminating this information can help more organizations access tools that have proven useful in California’s encounter data context.
As the Encounter Data Governance Entity, IHA is driving the adoption of standards throughout the data submission chain through the following mechanisms:
Encounter data quality challenges are extensive and require multi-faceted strategies to mitigate inaccurate and incomplete data submissions. A broad commitment among stakeholders, the value proposition for investing in in technical solutions and workflow redesign, and value-based incentive design are all critical to driving meaningful improvement and alignment. We’re pursuing an incremental approach that focuses on areas where there is early agreement, where the proposed remediations are relatively easy to implement, and where adoption can lead to measurable progress.
Yes. Since 2007, our Align. Measure. Perform. (AMP) programs have collected and reported encounter data quality measures. Currently, we use the following measures:
For provider organizations that participate in IHA’s Align. Measure. Perform. (AMP) programs, please visit the Performance Reporting Portal to access your encounter data results along with the rest of your AMP performance results.
Since 2007, IHA has helped the providers and health plans understand encounter data performance through our Align. Measure. Perform. (AMP) programs. Here are a few significant milestones in IHA’s trajectory: