Welcome to the MMCO 101 training on Medicare-Medicaid Plan or MMP encounter data.
This presentation is for MMCO staff who want to learn more
about the encounter data that MMPs submit to CMS We’ll go over why encounter data are important,
what encounter data actually are, how plans submit them to CMS,
how the MMCO encounter data team assesses completeness, and some ways CMS uses these data
Here’s some background if you’re not familiar with MMPs specifically or capitated managed care
plans more generally. In 2021 there are 40 MMPs operating in 9 states, under the capitated model
of the Financial Alignment Initiative. MMPs are fully integrated plans, meaning all or almost all
Medicare and Medicaid services are provided by the MMP. At the beginning of each month,
states and CMS pay MMPs a Medicare and Medicaid capitated payment, respectively,
for each enrollee. By capitation we mean a single monthly amount per person per month
(which is risk adjusted); plans do not bill CMS or the state on a per service basis.
Why are encounter data important? They are a critical resource for CMS, states and the
Medicare-Medicaid plans (MMPs) in monitoring, implementing, and evaluating these models.
What exactly are encounter data? Encounter data are data MMPs sent to CMS and states that show
the covered services they provided to enrollees. It is a record that simulates a bill for a service
rendered to a patient covered under a Capitated Plan. They have a lot of the same information as
a fee-for-service claim, for example, beneficiary information such as name and Medicare Beneficiary
Number; procedure and diagnosis codes; and provider ID information. What’s different, though,
is that the plan pays the claim, and is just letting us know about the covered service.
The three way contract with MMPs require them to submit all approved encounters to CMS
as well as to states. In sub-regulatory guidance, we clarify that they need to
submit Medicare encounters on separate files from Medicaid encounters.
We do this because we leverage the Medicare encounter data system.
That system has a multi-step process with Medicare edits and checks. They do not have information to
do similar checks on the Medicaid encounters. MMPs submit data on Medicare professional,
institutional and DME files. On the Medicaid side there are also files for professional,
institutional and DME, but also for dental (if covered in the state), and NCPDP
for Medicaid covered drugs. MAOs don’t submit the additional Medicaid files – Dental and NCPDP.
We call data on covered Medicare Part D-covered drugs “Prescription Drug Event” or
PDE – they come to CMS in a separate process. We also have frequency and timeliness requirements.
For frequency, we require the MMP submit at least one of each of the files monthly,
with the exception of South Carolina, where MMPs don’t cover dental services. The timeliness
requirement is for MMPs to submit encounters within 180 days from the date of service. Note
that these are MMP-specific requirements; Medicare Advantage plans have different requirements.
As mentioned earlier, states also require MMPs to send all encounters to them. There are three
exceptions: California, to whom we forward Medicaid encounters, and Illinois and South
Carolina, to whom we forward both Medicare and Medicaid encounters. States may have their own
formatting or other state-specific instructions. From the beginning of the demonstrations
we acknowledged the burden of this, and even built a “claimsplitter” to make it easier for MMPs,
but didn’t have any takers, so we know MMPs have figured out how to do this themselves.
How does the MMCO encounter team assess completeness? The short answer is we provide
a LOT of technical assistance to MMPs. We also use and are constantly evolving data analytics.
A key part of the team’s technical assistance to MMPs is biannual meetings. Every month
the team meets with each MMP in one or two states to go over a number of items, including Medicare
and Medicaid utilization charts, Inpatient RAPS Analysis, SNF Analysis, and MMP Error report,
with the result that they meet with each plan every six months. We also answer questions
plans have with submitting their encounters as well as other encounter data related issues.
State staff and MMCO state leads are also invited. The team launched biannual meetings in 2020,
and it’s very well received by plans, helping them keep up with issues on a flow basis.
A big reason for lack of completeness is when MMPs submit encounters, but don’t closely monitor
and work rejections. The Medicare encounter data system has five stages through which it processes
encounters, and can reject encounters at any stage. A few years ago, the MMCO encounter team
developed quarterly Monthly Summary Error Reports, which showed MMPs exactly which encounters failed
and where they failed. This saved MMPs untold time researching rejections to work. It was so
effective that Medicare Advantage automated it and provides it to all Medicare Advantage plans.
The MMCO encounter team also prepares “utilization charts” for major Medicare and Medicaid categories
of services. The charts compare utilization per member month to a plan-specific benchmark.
Any change more than 20% over or under the benchmark prompts additional analysis
and/or conversation with the plan. For the Medicare utilization charts,
we focus on utilization rates for inpatient, outpatient, professional, and SNF. We also compare
inpatient encounters to plan-submitted RAPS - data plans submit for each inpatient admission that
support risk adjustment. For SNF, we ask the plan to validate that the encounters are for a Medicare
skilled nursing facility service, rather than for a Medicaid custodial nursing facility service.
Finally, we confirm an encounter was for a SNF stay by linking it to MDS
assessment data, as these assessments are required for all SNF admissions.
For Medicaid utilization charts, we look at Medicaid behavioral health, non-emergency
transportation, home and community based services, nursing facility, personal care, and dental.
Here are a couple challenges we’ve faced and had to build mitigation strategies for.
Duplicate encounters – We tended to see a lot of duplicate encounters for Medicare services
where the same encounter showed up in the Medicaid file. We learned that while MMP policy is that
there are no copayments for Medicare A/B services, states wanted data on what the cost-sharing would
have been, so plans asked to submit encounters to them as 80% on Medicare, 20% on Medicaid.
We now know to look for this and merge them back to a single claim for our completeness analysis.
Errors in submitting on a Medicare or Medicaid file. As noted above,
MMPs have to submit Medicare encounters on separate files from Medicaid encounters.
We found that for “overlap” services of DME and home health that can be a challenge.
In this context, overlap means that it is not always clear whose the primary payer,
as the Medicaid benefit is more expansive than the Medicare benefit. A similar challenge was
being sure to submit SNF encounters in the Medicare file and NF encounters on the Medicaid
file. We found that where a plan defaults to sometimes depend on whether the plan started
as a Medicare Advantage plan or a Medicaid-only Managed Care organization. To further assist the
MMPs, we developed a how to split guide on what to allocate to Medicare or Medicaid.
The last tool we’ll discuss for promoting complete encounter data is quality withhold.
We withhold a small percentage of each capitation payment to the MMPs,
and only pay it out if they meet certain criteria. One is related to encounter data: we score them on
frequency and timeliness, where they need an 80% or better score to “pass”. For frequency,
they need to submit the following 4 files at least once a month – Medicare Professional,
Medicare Institutional, Medicaid Professional, and Medicaid Institutional. For timeliness,
encounters in all 8 files must be submitted within 180 days of service.
Much of our work is to assess completeness prior to the evaluation contractor using these data.
However, more and more, we are starting to pose our own questions using encounters. For example
in early 2021 we used encounters to measure the rates of COVID cases and hospitalizations. We’re
excited to grow our efforts in this area. Thanks for your attention today.
If you have any questions, please ask anyone on the MMCO encounter team!
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use
only and must not be disseminated, distributed, or copied to persons not authorized to receive the
information. Unauthorized disclosure may result in prosecution to the full extent of the law.