Streamline encounter management and risk adjustment

Consolidate and scale across all managed care programs.

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Revenue Integrity

Health plans must embrace encounters (and risk adjustment analytics) as crucial components of their revenue streams in order to secure revenue integrity for government and commercial programs. Unfortunately, many plans suffer from increased encounter lifecycle costs and lost revenue due to the use of disparate, siloed systems. Overcoming these challenges requires a consolidated encounter management and risk adjustment system for all programs and lines of business.

Our Approach

Health plans must embrace encounters (and risk adjustment analytics) as crucial components of their revenue streams in order to secure revenue integrity for government and commercial programs. Unfortunately, many plans suffer from increased encounter lifecycle costs and lost revenue due to the use of disparate, siloed systems. Overcoming these challenges requires a consolidated encounter management and risk adjustment system for all programs and lines of business.

Capabilities

Consolidate encounter management operations

Deliver a consolidated encounter lifecycle management system for all government and commercial programs.

  • Single platform for all lines of government and commercial lines of business including Medicare Advantage, managed Medicaid, dual eligible and the ACA/Marketplace.
  • Best in class compliance and workflow solution to streamline all submission operations, reduce associated costs and complexity and improve exception management.
  • Managed services for submissions (hosting infrastructure, submission operations management) to improve SLA adherence, reduce penalties and ensure business continuity.
  • Rapid implementation for new managed Medicaid states, with Edifecs managing continuous compliance, to enhance speed to market and SLA adherence.

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Enhance risk analytics and forecasting

Drive accurate and actionable risk adjustment analytics and revenue forecasting.

  • Dynamic intervention planning methodology prevents wasteful expenditure on ineffective interventions.
  • Integration with Edifecs Encounter Management ensures seamless encounter data submission, acknowledgement processing and reconciliation.
  • Visibility, real time reporting and access to data eliminating the need to maintain multiple reporting databases and resources, thus reducing IT impact.
  • Integrated dashboards provide real-time views into risk scores, forecasted payments and payment transfers.

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Streamline MAO/MCO encounter operations

Ensure accuracy, completeness and timeliness of CMS and state-based encounter submissions.

  • Generate both RAPS/EDPS formats from a single claim to reduce submission cost and complexity. Improve initial submission accuracy and reconciliation via a single system.
  • Utilize workflows for mass correction and review/approval to reduce manual processes and costs while improving re-submission accuracy.
  • Facilitate adherence to data submission SLAs thus avoiding financial penalties and improve health plan quality measure attainment.
  • Utilize Edifecs SMEs to provide on-going compliance with ever-changing rules and format updates to drive business continuity.

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