Client Results: Encounter Submission Management, Stopping Leaks

Risk Adjustment

Identifying gaps in an encounter submission service contract that totaled nearly $50M in missed revenue

Challenge

ProspHire assisted the client to identify and resubmit the uncaptured diagnosis codes valued at $41.1M. ProspHire also helped the client align on the go-forward submission management plan with the vendor and develop the necessary suite of reports to track all captured diagnosis codes from submitted to accepted and stored status as reported by CMS.

Solution

ProspHire identified a gap in encounter error processing by analyzing the CMS Encounter Data Report Cards. An operational assessment was conducted including key findings, error volumes, and potential financial impact. ProspHire partnered with the client’s Risk Adjustment team by filling the role of their submission vendor and error correction management team. The project team managed the weekly vendor management meeting between the client’s leadership team and the vendor to drive accountability and confirm the client’s needs and questions were addressed and resolved. As operational gaps were identified, ProspHire facilitated obtaining reports, processing the reports to identify uncaptured diagnosis codes, and creating the supplemental files for submission.

Result

ProspHire assisted the client with identifying and resubmitting uncaptured diagnosis codes valued at $41.1M. The client and vendor have agreed to collaborate on submission management and to create a long-term suite of reports to enable the client to track all captured diagnosis codes from submitted to accepted and stored status as reported by CMS.

Deliverables

$41.1M uncaptured diagnosis codes identified and resubmitted
Contracted Services Review
Operational Assessment
Submission Deadline Project Plan
New Vendor Generated Reports

Client Overview

The client is a large Medicare advantage organization that provides regional coverage and manages large self-insured provider groups at the nation and regional levels.