Medicaid Encounter Data – Project Spotlight

Dx Accuracy Reporting Review for Medicaid Plan

Client Challenge:

Cirdan’s client, a Medicaid Health Plan, was concerned that it had not accurately reported diagnosis codes for its members.

Our Solution:

Cirdan completed an analysis to review their current encounter submission process, identify missing diagnosis data and determine charts to review.

• Cirdan conducted an administrative review that found diagnosis codes were missing from their submission.
• Cirdan reviewed the submission process for voids and adjustments and found the process was inadequate and not complete.
• Cirdan identified charts for review through a historical review of claims incurred by members to identify chronic Diagnosis.
• Cirdan created submission files to add the missing diagnosis codes.

The Result:

The client was able to submit the missing diagnoses found in the administrative review and increase their revenue. The client is working to fix the voids and adjustments logic which will improve compliance and the accuracy of their claims payments. The missing diagnoses found throughout the chart review process were submitted and the additional diagnoses will increase future revenues.