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What happens when Medicare Advantage organizations discover that 95% of their encounter data submissions contain errors—but only after CMS (Centers for Medicare & Medicaid Services) has already processed them?
For most healthcare organizations, this scenario plays out monthly. Claims get rejected, revenue disappears, and audit readiness becomes a scramble to find documentation that should have been organized from day one. With CMS now auditing all 550 Medicare Advantage plans annually (a 900% increase from previous years) these operational gaps have transformed from inconveniences into existential threats.
Mirra’s EDPS Healthcare solution is specifically designed to optimize these operations. It automates the encounter data workflow, reducing human errors and ensuring compliance with CMS regulations. By eliminating documentation gaps and operational bottlenecks, Mirra’s system helps organizations streamline their processes and recover previously lost revenue.
The financial impact is significant: CMS data reveals that 9.5% of payments to MA organizations are improper, largely due to insufficient documentation. This is where Mirra’s EDPS comes in, providing the tools and strategies to manage encounter data more effectively. With Mirra, Medicare Advantage organizations can thrive, knowing their operations are optimized for both efficiency and regulatory alignment.
Why Traditional EDPS Healthcare Approaches Fall Short?
Most healthcare organizations struggle with fragmented encounter data processing systems that create multiple vulnerability points:
Revenue Leakage: Inaccurate risk scoring costs payers $50-80 per member per month, while conservative coding leaves significant revenue on the table.
Documentation Gaps: Missing or incomplete medical records trigger audit flags, with lack of medical necessity being the primary cause of improper payment determinations.
Operational Bottlenecks: Manual processes cannot handle the volume demands of modern Medicare Advantage operations. With CMS expanding audits to cover approximately 550 MA plans annually, manual approaches become completely unsustainable.
Real-Time Blind Spots: Traditional systems cannot identify coding errors or documentation gaps before submission, forcing organizations to discover errors only after CMS rejection when correction costs are highest.
For organizations looking to establish a comprehensive Medicare Advantage program, understanding these challenges is crucial for building sustainable operations from the ground up.
The Role of Claims Adjudication in Building Robust EDPS Healthcare
For Medicare Advantage organizations, effective claims adjudication within encounter data processing systems plays a vital role in maintaining risk adjustment accuracy and regulatory compliance. When Medicare Advantage claims processing operates with precision, it supports organizational goals while meeting CMS requirements that have become increasingly stringent.
Here are the key components that illustrate how claims adjudication contributes to a robust encounter data processing system for Medicare Advantage plans:
Accurate Risk Scoring
Well-implemented EDPS healthcare systems help ensure that diagnosis codes appropriately reflect patient health needs, supporting appropriate reimbursement for higher-risk patients while maintaining documentation standards that align with audit expectations.
CMS Compliance Integration
Advanced EDPS healthcare platforms, such as those offered by Mirra Healthcare, incorporate HIPAA and CMS-specific validation checks directly into the encounter data workflow. This proactive approach helps organizations address potential issues during processing rather than after submission, streamlining the compliance process.
Technology Integration
Mirra’s modern EDPS healthcare solution addresses the challenges of fragmented systems by providing integrated data workflows from clinical documentation through CMS submission. This comprehensive approach helps organizations maintain data integrity and operational efficiency while supporting their compliance objectives.
Strategic Benefits of Proactive EDPS Healthcare Optimization
Organizations that invest in comprehensive EDPS healthcare solutions achieve measurable competitive advantages:
1. Quantified ROI
Penalty avoidance, revenue optimization, and operational efficiency gains deliver clear financial returns. Organizations reduce audit-related costs while capturing previously missed revenue from accurate risk adjustment.
2. Market Positioning
Superior EDPS healthcare accuracy enables organizations to maintain stronger payer relationships, secure favorable contracts, and reinvest savings into service improvements.
3. Risk Mitigation
Proactive audit readiness through robust EDPS healthcare systems helps reduce the chances of regulatory issues and builds compliance confidence with CMS.
Learn more about Mirra's comprehensive suite of healthcare solutions and how they can support your organization's compliance and operational goals at our insights and services overview.
Why Healthcare Organizations Trust Mirra for EDPS Healthcare Solutions
With CMS auditing all 550 Medicare Advantage plans annually and increasing scrutiny on every submission, manual processes simply can't keep up. Organizations are losing revenue to preventable errors while spending countless hours preparing for audits.
How Mirra Changes This
Instead of your team manually checking thousands of encounters and scrambling during audit season, Mirra handles the heavy lifting automatically. Your revenue improves because fewer claims get rejected, your staff focuses on patient care instead of paperwork, and when auditors call, you're ready.
Mirra's Integrated EDPS Healthcare Solution
Mirra's comprehensive platform addresses the complete compliance workflow, from encounter data processing through audit preparation:
1. Advanced Processing Capabilities
The system receives, processes, and transmits complete and compliant 837 data to CMS while applying responses automatically. Real-time HIPAA and CMS-specific edits ensure compliance before submission.
Example: A Medicare Advantage plan submitting 10,000 encounters monthly reduces processing time from days to hours through automated validation and formatting.
2. Intelligent Error Management
Mirra ranks and prioritizes error correction activities by HCC impact, automatically classifies encounter rejections by type, and tracks diagnoses back to source files for complete reconciliation.
Example: When CMS rejects 150 encounters, the system automatically prioritizes 45 high-value diabetes complications (HCC 18-19) for immediate attention, potentially saving $50,000+ in lost revenue.
3. Automated Audit Readiness
The platform reconciles discrepancy gaps between Claims, EDPS, RAPS, MAO-002, and MAO-004 automatically, maintaining audit-ready documentation with comprehensive tracking capabilities.
4. Real-Time Monitoring
Built-in dashboards provide visibility into file status, encounter error distribution, and CMS acceptance rates, enabling proactive management of EDPS operations.
Results We Deliver:
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Revenue recovery from previously rejected claims
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Staff time redirected from manual reviews to strategic work
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Confidence during CMS audits with complete documentation trails
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More staff time is available for patient-focused activities instead of administrative tasks
Conclusion
Most organizations implementing Mirra’s EDPS solution are fully operational within 8-12 weeks, including training your team and integrating with existing systems. We work alongside you throughout the implementation and provide ongoing support as regulations evolve.
The goal isn't just compliance - it's giving you the tools to thrive in an increasingly complex regulatory environment.
Schedule a personalized no-obligation demonstration to see precisely how Mirra can streamline your encounter data processing and strengthen your audit readiness.
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