A duplicate encounter is any encounter that contains the same service line level information as a previously submitted encounter. Duplicate encounters are a leading cause of encounter rejections and a major pain point for encounter data quality. The recommended actions outlined here are intended to reduce duplicate encounter submissions, particularly for plans and providers serving Medi-Cal enrollees.
IHA in partnership with the Health Industry Collaboration Effort (HICE) and their Encounters Standardization Team (HICE Encounters Team)
Why use it
Duplicate encounters are one of the leading causes of submission rejections and poor encounter data quality. This widespread issue affects plan and provider organizations across all lines of business, often consuming staff time and resources. Duplicate encounters also directly impact the overall timeliness of encounter data throughput to the California Department of Health Care Services, which oversees Medi-Cal. Duplicate submissions are linked to worsened data quality which impacts capture of services provided, risk adjustment and/or rate setting, as well as quality measurement and reporting of encounter data quality.
Though instructions and formats exist to streamline the encounter dataflow, there is a need for additional defined processes, workflows, and consensus-based recommendations to improve communication in the encounter data reporting process. Encounter data subject matter experts prepared recommended actions to clarify processes and standards for California regulators, plans, and submitters that utilize encounter data, with the goal of addressing the root causes of duplicate encounters.
Who it’s for
This resource is intended for California regulators, plans, clearinghouses, and submitters (Managed Services Organizations, provider practices, Independent Physician Associations) that utilize encounter data, particularly those that participate in Medi-Cal.
Through consultation with provider and health plan representatives across California, the authors identified the need for the healthcare community to adopt or adhere to industry standards in the following areas:
- The industry should create specific, aligned definitions and processes to indicate encounter submission status (e.g., rejected, accepted, in process, etc.). For example, the 277 Claim Acknowledgement is a X12 standard that can be utilized by health plans to communicate to their submitters whether or not encounters have been accepted into the health plan’s system. Submitters can use the 277 files to log and track encounter submission status.
- The industry should align on the information fields that each organization includes in any encounter data reconciliation report, and data exchange partners should determine a cadence upon which to review the reconciliation report together. As of November 2022, the HICE Encounters Team is developing a Reconciliation Report Template informed by industry participants that will be available on IHA’s Encounter Data Resource Hub.
- The industry should institute/implement a standard identifier to notify plans that a submitter is resubmitting (i.e., fixing) an encounter that has already been submitted but has not yet been rejected or accepted.
- The instructions detailed in the DHCS’ Companion Guides’ section 3.8 “Duplicate encounters” on identifying duplicate encounters – also referred to as “duplicate logic” – should be upheld and adhered to as the industry standard.