The Upside of Encounter Data
Back in the good ole’ days of Medicaid fee-for-service (FFS), providers would submit their bills directly to a state’s Medicaid program and then receive payment based on the submitted charges; however, just like the days of free TV and pet rocks, FFS’s days are numbered. Over the past twenty years nearly half of all states have moved to a Medicaid managed care delivery model. In the new Medicaid managed care world, the requirement for comprehensive and accurate encounter data has become increasingly critical; however, often in the seemly endless quest to supply the state Medicaid agency with what they need, we overlook the goldmine of data delivered to our door.
When reviewing encounter data, if a data element is an outlier to either extreme, grab a shovel and start digging. Outliers can highlight problems with your data or with your current business process – or (insert audible gasp) both. For example, encounter data can show you quite clearly what services are being rendered to which segment of your population. Are your rural customers utilizing emergency services more frequently than your customers located in urban areas? If so, does your rural physician network need expanding to allow customers access to care outside of an emergency room setting? Do you need to consider alternative delivery methods for your rural population?
Encounter data can help distinguish:
1. Utilization trends
2. Network gaps
3. Customer education gaps
4. Utilization management misalignment
5. Rate inconsistencies
6. Miscellaneous/Unlisted code usage
So, while encounter data is almost universally troublesome to assemble and transmit, it also delivers a wealth of information to your feet for those willing to reach down and pick it up. Go ahead, pick it up; it won’t bite and we here at Catalyst can help tame the encounter data beast (whip and chair included).