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Elevating Healthcare Operations

Avoiding Inaccurate CMS Data Submissions and Supercharging Your Data Process

$30-$50 PMPY is lost by health plans due to underreported risk in Medicare Advantage (MA) and Affordable Care Act (ACA) markets, according to our recent data analysis. Capturing this lost revenue and achieving end-to-end encounter quality requires complete and accurate data from encounter to submission. A deep understanding of the process’ complex web of systems and ongoing updates is vital.  

One of our most recent webinars, Unlocking Success: Best Practices for Monitoring Health Plan Data Submissions to CMS, was designed to help health plans gain that understanding and realize the consequences of inaccurate CMS data submissions.

Our expert panel shared their considerable real-world experience to address the costs of inaccurate encounter data, their complex operational workflow, and ways to improve the overall submission process.

The true cost of inaccurate CMS data submissions

The complex encounter data process creates many issues for health plans. These are three significant areas of impact:

  • Compliance exposure. CMS is increasing audit scrutiny on health plans in all regulated markets.
  • Lower financial reimbursement. Underreported risk can lead to suppressed risk scores and an average $30-$50 PMPY impact for the MA and ACA markets.
  • Lack of member insights. Plans may be acting on an incorrect profile of their members, resulting in prioritizing the wrong efforts.

All plans evaluated in our analysis had issues that were suppressing revenue.

To ensure accurate encounter data, it's important to have a thorough understanding of the data process. Even if you have a wealth of information within your system, process issues can still arise and lead to flawed decision making. Addressing systemic issues early on is crucial to avoid spending administrative resources on closing gaps year after year.

Points of failure

We've uncovered that 60% to 85% of issues are set before the data gets submitted to the government.

1. Encounter data challenges

Our client analyses have uncovered many issues impacting that path: manual processes, data aggregation, and system limitations.

  • An integrated provider system manually submitted batch data to their health plan partners. Depending on the time of day the process was run, encounters were left off the CMS data submission. It was less than 1% of all encounters, yet it amounted to approximately $5 million for a medium-sized health plan.
  • A risk-bearing provider aggregated data and the disparate data sources were misinterpreted and not working as they should. This led to a reduction of a star for two measures—breast cancer screening and diabetic retinal eye exams.
  • The most common issue we run into is system limitations that impact providers' ability to submit all diagnoses on a claim or to get all the diagnoses to the plan if they can’t fit. This means continually spending dollars on chart reviews.

2. Pre-submission data challenges

Through our data integrity solution, Pareto identified clients’ primary challenges that arise from internal processes before submission activities.

  • 837 post-adjudicated claims
    • Diagnosis code truncation
    • Submission timing
    • Provider specialty mismatch
  • Vendor data gathering (incomplete data to encounter vendors, provider system limitations, and service code changes)
  • Full evaluation review (risk-bearing evaluations and past issue evaluations)

3. Submission challenges

Market-specific issues impact our clients during their CMS data submission processes, and the complexities continue once you get the data submitted.

  • ACA market—Plans leave membership off enrollment commissions, leading to claims being excluded from the transfer payment calculation.
  • Medicare Advantage market—We're still seeing struggles with EDS encounter processes and how to remediate them efficiently.
  • Medicaid market—Rules vary from state to state. Common issues include providers needing to register with the state, encounter submission window limitations, and Medicaid Management Information System (MMIS) claims submitted without the appropriate disposition code.

What can you do?

1. Evaluate current encounter data process

Conduct an independent evaluation of your current processes to identify potential compliance and financial exposure. Health plans must ensure that 100% of the data within your four walls get to your vendors or internal submission teams.

2. Establish ongoing controls

Systems, personnel, and regulatory requirement changes constantly present new issues impacting the end-to-end encounter process. Ongoing controls allow you to proactively address issues before regulatory submission deadlines.

3. Proactively oversee vendors

Many health plans outsource the encounter data submission process, and most still need to establish oversight controls. Ensuring that your vendor is receiving all data accurately and then submitting it completely and compliantly to the government on your behalf is critical.

4.  Scrutinize the data received

Plans overspend on chart reviews instead of addressing the system limitations impacting risk documentation completeness and focusing on prospective risk capture. Pair chart results and claims data to pinpoint the root causes affecting risk scores and minimize the cost and administrative burden.

The time to make improvements is now

  • ACA market—Take advantage of blackout periods to evaluate and adjust processes and agreements.
  • Medicare Advantage market—There’s little time to impact Medicare Advantage 2022 performance, so it’s time to turn attention to January 31
  • Medicaid market—Ensure all data gets submitted and positively impact your future rate setting and performance standards.

Get full insights by watching our webinar replay

The webinar covers much more than we can put into one article, including detailed case studies and a Q&A session. Click ahead to view the full replay:

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