Avoiding Medi-Cal Encounter Reporting Issues

Problem to Solve

A major California health care organization found itself unable to meet Medi-Cal’s encounter reporting requirements and faced substantial financial penalties for its non-compliance. The organization’s legacy system had difficulty delivering the complex data that Medi-Cal required. Additionally, Medi-Cal encounter reporting requirements were growing and becoming more difficult, exacerbating the issue.

Before it began incurring Medi-Cal penalties for encounter reporting deficits, the health care organization acted quickly to address its needs and engaged Freed Associates (Freed) to manage its efforts. Freed knew the organization and the complexities of Medi-Cal data compliance well, and could provide the objective support needed to properly assess and sustain this initiative.

Strategy

The health care organization needed to deliver several years’ worth of encounter data to Medi-Cal, as well as comply with ASC X12 EDI standards. Because this project affected more than a dozen of the health care organization’s contracted Medi-Cal plan partners, Freed also needed to manage and coordinate reporting-related issues and communications among the plan partners.

Besides overall project management strategy and execution, including collecting and maintaining all project-related documentation and communication, Freed worked with the health care organization on the following:

• Improved budgeting and financial forecasting – Created a matrix to capture actual and forecast costs for continued Medi-Cal encounter reporting, oversee procurement processing and coordinate inter-departmental meetings
• Coordinated Medi-Cal contact – Supported re-processing approximately 2 million prior Medi-Cal encounters and 3.3 million new Medi-Cal encounters
• Coordinated plan partner contact – Established and facilitated recurring plan partner meetings, issue tracking and resolution, and ongoing communications
• Enhanced encounter tracking – Created a matrix communicating the delivery status of Medi-Cal encounters and improved an existing inventory matrix to more efficiently provide encounter delivery status for plan partners
• Delivered EDI analysis and support – Provided ASC X12 research, analysis and input to improve encounter reporting capabilities
• Built an automated renewal system – Created an SAS/Windows prototype to automate the renewal of the NPI registry needed for encounter processing
• Created transition documentation – Provided a transition plan for the client’s error corrections operations manager and new executive director of pricing systems and data services

Results

After several months, the project team began delivering to Medi-Cal its required encounter reporting data. This meant that the client would no longer need to rely on its prior, ineffective encounter reporting solution, and could proceed with a more capable and accurate reporting system.

Ultimately, the new encounter reporting solution provided the type and degree of data quality, completeness and timeliness that Medi-Cal sought. This new system also improved the health care organization’s ability to detect and resolve encounter reporting errors, as well as reduce the number of issues affecting the organization’s plan partners.

 Conclusion

Strategically and methodically, the health care organization built a new encounter reporting solution, and became data-compliant, able to deliver on its backlog of prior encounter data, and mitigate potential financial losses from Medi-Cal penalties.  The organization also created a workable, systemic approach for delivering future data, including creating a vital error correction and re-submission team.