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How Can Encounter Data Processing Revolutionize Medicare Advantage

07 Feb, 2024

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How Can Encounter Data Processing Revolutionize Medicare Advantage

In the Medicare Advantage domain, every digit in Encounter Data matters. A single error can create a complex chain reaction. Considering this, an intelligent and powerful Encounter Data processing system is a must in today's healthcare landscape.

This blog post will help you quickly understand encounter data, the importance of encounter data processing services, and their benefits. From cracking encounter data processing challenges to understanding & navigating ever-changing rules, we're not just talking problems – we're talking solutions. Let’s get started.

Why is Encounter Data of Critical Importance in Medicare Advantage?

Encounter data is like a digital diary of a patient's healthcare journey. It's a detailed record of every visit, every prescription, every test – a virtual breadcrumb trail of patient care. This data captures the medical procedures and the intricate details of the encounter, including diagnoses, procedures performed, and even the providers involved.

Now, you might wonder why this data matters so much. Let’s put it this way: accurate encounter data is like a treasure map for health plans. It helps them navigate through the complexities of healthcare management and find data processing solutions.

Risk Adjustment: Encounter data plays a starring role in calculating risk scores, which in turn decide the level and quality of reimbursements. When data captures the complexity of a patient's condition, it leads to accurate risk scoring. For instance, patients with chronic illnesses require extensive care. By inputting precise Encounter Data, we ensure they receive the necessary care without delays.

Reimbursement Accuracy: Health plans receive payments based on the health conditions they manage. Correct encounter data ensures that health plans are appropriately compensated for the care they provide. When data accurately mirrors patients' health realities, health plans can effectively distribute resources and provide optimal levels of care in quantity and quality.

Performance Evaluation: Picture encounter data as a mirror reflecting a health plan's performance. Health plans gain the insight needed to pinpoint areas for improvement through a meticulous analysis of this data. This intricate evaluation process empowers health plans to tailor strategies, aiming to improve patient outcomes with pinpoint accuracy.

Read more: 4 Benefits of Outsourcing to Third-Party Administrators | Mirra HC

A Real-World Scenario and its Possible Implications

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Consider this scenario: A health plan receives Medicare Advantage encounter data that shows a patient's condition as less severe than it is. The risk score generated from this data doesn't match the reality, leading to inadequate plan reimbursement. The patient's required healthcare needs must be fully addressed, affecting their well-being. Now, think of the opposite scenario – accurate encounter data ensures patients get the care they need.

Inaccurate encounter data doesn't just affect numbers on spreadsheets; it affects real people. That's why understanding encounter data isn't just about deciphering codes; it's about safeguarding patient health and well-being.

Challenges in Encounter Data Processing

Challenges in Encounter Data Processing

While encounter data promises a wealth of insights, its processing is challenging. Health plans find themselves navigating through many challenges to ensure accurate and meaningful data processing and analysis:

1. Coding Accuracy and Specificity

Ensuring that each code reflects the diagnosis or procedure is a tightrope walk. Misinterpreted regulations lead to denied claims and revenue loss. The transition from ICD-9 to ICD-10 brought heightened specificity, requiring meticulous code selection to capture the complexity of patient conditions and treatments.

2. Evolving Coding Guidelines and Regulations

The coding rulebook is a constantly evolving manuscript. Health plans must adapt swiftly to changes from regulatory bodies like the Centers for Medicare & Medicaid Services (CMS). Staying current and compliant demands constant staff education and vigilant coding practices.

3. Technology Integration and Interoperability Issues

Bringing together coding systems and electronic health records is like fitting pieces of a jigsaw. Ensuring seamless data flow and accurate code assignment across platforms remains a challenge.

4. Data Security and Compliance Concerns

Adhering to Health Insurance Portability and Accountability Act (HIPAA) regulations is paramount. Hence, handling patient health information (PHI) is a responsibility that must be taken seriously. Striking a balance between data accessibility for coding and maintaining stringent privacy measures is challenging.

Read more about Medical Risk Adjustment - A 10 Step Plan to Implement It Successfully

How Can Mirra’s EDPS Solution Solve Your Problems

How Can Mirra’s EDPS Solution Solve Your Problems

This is where Mirra Health Care's Encounter Data Processing System (EDPS) steps in. It's not about just rectifying errors; it prevents them from happening in the first place.

Focused Error Correction

Our EDPS targets the high-impact issues first, using HCC risk prioritization. This ensures that the most significant problems are tackled head-on, boosting the accuracy of risk adjustments.

Benefits: This approach doesn't just fix errors; it boosts the accuracy of risk adjustments. The tangible benefit for health plans is that they can rely on precisely calibrated risk scores, leading to fair reimbursements and optimized resource allocation.

Simplified Compliance

Compliance is non-negotiable, especially with CMS rules. Our EDPS simplifies this by aligning with CMS requirements to prevent discrepancies that can trigger audits.

Benefits: Health plans enjoy a smoother journey through compliance hurdles, avoiding discrepancies that could trigger disruptive audits.

Read more: Optimize Healthcare with BPaaS Solutions | Mirra HC

Real-time Error Management

Our EDPS actively manages and interprets CMS error reports in real time. This proactive approach ensures swift resolutions, keeping operations smooth and free of delays.

Benefits: The direct use is swift resolutions. Health plans can maintain streamlined operations, ensuring no bottlenecks impede patient delivery of crucial care services.

Aligned Data Sources

The complicated relationship between Claims, EDPS, MAO-002, and MAO-004 can lead to gaps. Our EDPS acts as a bridge, reconciling discrepancies and ensuring data consistency across sources.

Benefits: This means seamless data flow for health plans, preventing costly gaps and delays in understanding and decision-making.

Precision Checks

Our EDPS puts data under a magnifying glass. It applies precise edits, both in terms of HIPAA and CMS regulations, before sending encounter data to CMS.

Benefits: What does this mean for health plans? Data sent to CMS must be corrected and fully compliant with all regulations and requirements, safeguarding against potential penalties and complications.

Read more about MRA Compliance: Challenges and Opportunities - By Pariksith Singh, MD

Why Choose Mirra’s EDPS for Your Success

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Why Mirra Should Be Your EDPS Solution Provider

Selecting a reliable Encounter Data Processing System (EDPS) provider for healthcare data processing is the first step toward seamless and accurate encounter data management. Mirra Health Care's EDPS stands out as a comprehensive solution designed to address the challenges faced by health plans.

Mirra’s Expertise

When considering an EDPS solution, look for a provider with a proven track record in healthcare data management. Mirra Health Care brings a wealth of experience and expertise, making it a trustworthy partner in your journey towards efficient encounter data processing.

Mirra Allows for Training and Education

Implementing an EDPS solution goes beyond technology; it requires an investment in training and education. Ensure that your team is well-versed in utilizing the system effectively. Mirra Health Care offers resources and support to ensure your staff is fully equipped to leverage the system's capabilities.

Mirra Builds Effective Processes

Integrating EDPS into your operations means establishing streamlined processes that address error management and resolution. Develop protocols that allow quick identification and correction of data discrepancies. Mirra's EDPS is designed to streamline this process, helping health plans meet compliance requirements.

Mirra Has Monitoring Systems in Place

Implementing an EDPS solution is an ongoing journey. Regularly monitoring key performance indicators (KPIs) is essential for continuous improvement. Measure the accuracy of encounter data, track error resolution times, and assess overall system efficiency. This proactive approach ensures that your encounter data processing remains on track.

The Bottom Line

Implementing EDPS empowers health plans with precise risk assessment and informed decision-making. Accurate encounter data processing is pivotal for your Medicare Advantage success. Mirra Health Care's EDPS tackles challenges head-on, streamlining operations, enhancing compliance, and optimizing financial outcomes.

Explore the potential of Explore the potential of our Medicare Advantage in a Box solution and revolutionize your encounter data management for excellence. Start your journey to success today. Call us for a demo

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Reviews & Testimonials


NANCY GAREAUCEO of Ultimate Health Plans

"In 2021, Ultimate Health Plans (UHP) partnered with Mirra Health Care (Mirra) to develop a software platform to support processing Claims, Customer Service, Eligibility, Enrollment, Premium Billing, Encounter Processing and a Provider Portal for our Medicare Advantage Plans. Mirra collaborated well with our operations and compliance teams to successfully design and implement a system that was innovative, efficient, and compliant with all Medicare and Florida Medicaid guidelines and requirements all within the scope of our required timeline. We greatly benefitted from the Mirra Project Management Team’s regular communication with Stakeholders through monthly meetings and recurring weekly breakout-focused calls, which were geared towards troubleshooting and goal alignment. Mirra was able to quickly maneuver and adapt their systems to our needs, resulting in successful implementation and go-live. Mirra continues to support our compliant operation and growth in the ever-changing healthcare industry rapidly and effectively updating their systems with new Medicare and Florida Medicaid rates and guidelines to ensure seamless compliance and efficiency. I have absolutely no reservation in recommending their systems to any Payer searching for improvement in their operational efficiency."

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