CMS Encounter Data – Project Spotlight

Data Quality Review – I-SNP Plan

Client Challenge:

Our client, a start-up Medicare Advantage Institutional Special Needs Plan (I-SNP), had concerns about the quality of its Encounter Data Submissions (EDS) data.

Our Solution:

Cirdan reviewed the EDS submission and response files and compared them to detailed paid claims data:

• Cirdan identified an entire category of claims for which EDS submissions were completely missing.
• Cirdan found that submissions had been completely missed in certain months.
• Cirdan found incomplete processes where only a subset of the Dx codes had been submitted in certain months.
• Cirdan found that claims from certain billing providers were not submitted

The Result:

By correcting these issues, annual revenue for the plan was increased by $500,000 for a plan with fewer than 500 members.