ENCOUNTER RECONCILIATION AND VALIDATION
PAST AND CURRENT SERVICES
- Develop data warehouse of managed care capitation claims or financial transactions, as well as managed care encounter claims. Request, receive and analyze financial information submitted by managed care organizations.
- Perform testing and analysis of encounter claims included in the fiscal agent contractor’s Medicaid Management Information System (MMIS) to files maintained by managed care organizations (MCO).
- Conduct routine meetings with MCOs regarding encounter claim submission issues.
- Conduct testing and analysis to confirm MCO financial and transactional processes, including testing of subcontractor encounter claim processes for fee‑for‑service and sub-capitation reimbursed services.
- Perform data mining and analysis on cash disbursement journals submitted by MCOs and subcontractors (delegated vendors).
- Prepare reports of encounter claim compliance issues with details of completeness and accuracy of encounters.
- Test compliance of MCOs to regulations and contract requirements.
- Provide assistance for developing and confirming compliance with corrective action plans and sanctions imposed on MCOs
- Perform analysis and audit of utilization rates (e.g., immunization, screenings, etc).
- Operational review of the process used by health plans to aggregate and tabulate encounter data.
- Comparison of encounter claims to the content of patient medical charts to examine whether data reported on the claim was accurately reflected in the patient medical record.
- Analysis and comparison of health plans from other states.
- Perform analysis of contractual standards, industry best practices, National Committee for Quality Assurance (NCQA) standards, Healthcare Effectiveness Data and Information Set (HEDIS) measures and other accepted protocols. Conduct on-site assessments of the health plans’ functions for encounter claims. Assist states in developing corrective action plans and/or contractual sanctions to cure deficiencies in MCO operations, and monitor compliance and correction of deficiencies.