Encounter Data Improvement Program: Improving Medi-Cal Care & Reducing Health Disparities
Date: 03/10/21
Encounter Data is Key to Increasing Access & Quality of Health Care
One of the state's most experienced and long-term managed care plans, Health Net is committed to bridging the divide in access and quality of care for California's most vulnerable patient populations. As part of this mission, we've committed $50 million to tackle a longstanding, complex challenge impacting patients, providers and plans today – encounter data collection and reporting.
In managed care setting where there's no standard claim submission process, providers collect "encounter data" during each patient visit or interaction within the health care system, which serves as a record of patient conditions and services and is then submitted to managed care organizations for reimbursement. This information helps track health care quality and costs, monitors population health trends and is key to identifying deficiencies or gaps in care. However, this data has been historically fragmented and inconsistent due to the complexity, administrative burden and a lack of standardization.
Health Net's Program & Partnership with the State
To continue to improve the state's Medi-Cal delivery system and reduce health disparities impacting underserved communities, we need accurate population health data and the critical insights that come along with it. Envisioned in collaboration with the Department of Managed Health Care (DMHC), the Encounter Data Improvement Program (EDIP) is a comprehensive $50 million funding initiative designed to overcome the barriers to timely, complete and accurate encounter data and inform real solutions. The multi-phased program is grounded in evidence-based research and deliberate action including:
- An Encounter Data Market Research Study
- One-Time Immediate Improvement Funding
- Provider-Level Assessment & Implementation Grants
- Multi-Stakeholder Engagement Process
- Established Organizational Oversight
Encounter Data Market Research Study
In 2018, Health Net awarded the Integrated Healthcare Association (IHA), a non-profit with over 25 years of experience in health care and proven expertise in aligning the industry to create solutions for better care, with a grant to complete a market research study to assess what blend of investments would maximize improvement of encounter data submissions. IHA conducted more than 60 interviews with frontline providers, practice staff and vendors to identify the factors that most contribute to poor encounter data quality including:
- Lack of understanding and education among stakeholders regarding encounter data and its value
- Lack of incentives for providers to submit timely and complete encounter data
- Inadequate training on data submission at the provider level
- Technology challenges and variable technology across clinical settings
- Variable quality control in encounter data submissions
- Poor communication among all parties involved in the data submission
- Lack of standardization – specifically around coding
- Issues specific to Medi-Cal patients, such as increased likelihood of fragmented care, difficulty verifying coverage and encounter data gaps
Encounter Data Improvement Pilot
In the Fall of 2017, Health Net provided $2.5 million in grants to 10 Medi-Cal managed care providers to address immediate encounter data improvements prior to the Phase 1 program outlined below. These funded projects focused on infrastructure enhancements, capacity building and staff training.
Provider-Level Encounter Data Assessment
Phase 1 - Assessment Grants: Health Net provided grants to 19 Medi-Cal managed care providers to assess their current encounter data submission processes and identify recommendations to increase the volume, accuracy and quality of data at the provider level. The results were analyzed by a consultancy, Harder + Company, into several high-level recommendations including:
- Upgrade technology and electronic health record systems
- Provide standardized trainings for provider staff
- Create more robust policies/procedures for data submission
- Automate encounter data reporting processes
- Improve internal workflows/communications
- Employ certified coders in clinical settings
Phase 2 - Implementation Grants: To test these recommendations, Health Net awarded 13 providers start-up funds to implement improvement plans. Final Phase 2 evaluations are expected in Spring 2021, but interim reports found that grantees were already seeing improvements because of funding, including:
- Increased focus on data quality by staff
- Enhanced coordination across departments and more streamlined submission processes
- Improved understanding of common error sources
Multi-Stakeholder Engagement Process
To ensure industrywide collaboration, Health Net provided a grant to Manatt Health Strategies to convene two healthcare stakeholder summits. Actionable strategies for encounter data improvement were developed by workgroups – comprised of high-level representatives from providers, plans, managed service organizations, clearinghouses and state and county governance – with recommendations presented during an August 2020 Data Summit.
The creation of a governance entity charged with overseeing and coordinating encounter data improvement initiatives was the most significant recommendation from this engagement program.
Establishing Organizational Oversight
Health Net committed $26 million of EDIP's budget to establish oversight of encounter data improvement efforts in California. After a robust RFP process, IHA was selected to oversee, monitor and implement encounter data improvement efforts across California including:
- Establish a statewide governance body to develop and organize policies, standards and processes;
- Develop standardized systems and coding for data submissions; and
- Develop encounter data trainings, technology support and technical assistance programs for providers and staff.
Alignment with CalAIM
Health Net is proud to contribute to the development of solutions that directly support the Department of Health Care Service's CalAIM initiative to advance and innovate within Medi-Cal managed care. Health Net looks forward to continuing to collaborate with the Department to strengthen encounter data collection in California – ultimately driving better health outcomes and increased quality of life for all patients.