As the Encounter Data Governance Entity (EDGE), IHA is coordinating a statewide effort to improve encounter data. Through a multi-pronged approach, including technical assistance, performance measurement, industry engagement, and communication efforts, we’re aligning the healthcare community around a shared goal: to ensure that all future reporting dependent on encounter data reflects actual provider and health plan performance and an unbiased understanding of population health needs.
As a contingency of Centene’s acquisition of Health Net, the California Department of Managed Health Care (DMHC) required Health Net to invest $50 million in improving encounter data submissions in California, with a focus on Managed Medi-Cal providers. Health Net launched its Encounter Data Improvement Program (EDIP) in 2015 through a series of grants. In 2019, Health Net oversaw an industry listening process led by Manatt Health. This listening process highlighted the need for a Governance Entity to steward cross-industry alignment. Through a competitive RFP process, Health Net selected IHA as the Governance Entity in March 2021 with the charter of overseeing a multi-year, cross-industry effort to improve the completeness and reliability of encounter data in California.
IHA’s role as the Encounter Data Governance Entity (EDGE) is funded by Health Net, Inc as part of the California Department of Managed Health Care’s undertakings for Centene Corporation’s acquisition of Health Net. IHA’s work as the Encounter Data Governance Entity is governed through a milestones-based contract with Health Net, Inc.
Encounter data across California’s healthcare delivery system is fragmented and inconsistent due to the complexity, administrative burden, and a lack of standardization in how the data is submitted and processed. As a result, data gaps, rejections, and duplications threaten the reliability of the many reports and processes that are dependent on encounter data.
While this problem is particularly acute in California due to the prevalence of managed care and capitation payment arrangements in the state, encounter data management is a challenge for the healthcare system nationwide, especially as more stakeholders adopt or expand population-based alternative payment models.
To pull off a statewide encounter data improvement effort, we’re working with leading organizations in provider technical assistance, industry collaboration, and those who manage encounter data for their programs. This includes California Medical Association, California Primary Care Association, the Department of Health Care Services, the Department of Managed Health Care, and Health Industry Collaboration Effort.
Learn more about the organizations taking part in this effort.
Our work as EDGE has a strong focus on Medi-Cal. However, we seek to implement industry-wide advancements across all product lines and geographies. This is because the challenges associated with poor quality and missing encounter data are not limited to Medi-Cal, and many of the stakeholders that submit and process this data operate across multiple lines of business.
According to the Centers for Medicare and Medicaid Services, encounter data is “detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.” A “capitated managed care entity” refers to providers and health plans who receive a per-member-per-month capitated rate to care for an assigned patient population.
Many important healthcare processes rely on encounter data, including:
Data standards determine and align standard sets of codes, processes, or guidelines to help ensure data consistency and usability. While instructions and formats exist for encounter data — such as various companion and policy guides from the Department of Health Care Services (DHCS), there is a need for additional defined processes, workflows, and consensus-based recommendations to improve how encounter data is collected, reported, aggregated, and analyzed.
For example, a multistakeholder workgroup can establish a standard guideline or crosswalk for translating local codes prior to submission. Such a solution would ensure that encounter data submissions aren’t inappropriately rejected or reporting doesn’t lose accuracy when aggregated across different organizations or regions. Another example of a data standard is defining modifiers and logic design for a specific coding scenario that feeds into encounter data reporting. Developing and disseminating this information can help more organizations access tools that have proven useful in California’s encounter data context.
As the Encounter Data Governance Entity, IHA is driving the adoption of standards throughout the data submission chain through the following mechanisms:
Encounter data quality challenges are extensive and require multi-faceted strategies to mitigate inaccurate and incomplete data submissions. A broad commitment among stakeholders, the value proposition for investing in in technical solutions and workflow redesign, and value-based incentive design are all critical to driving meaningful improvement and alignment. We’re pursuing an incremental approach that focuses on areas where there is early agreement, where the proposed remediations are relatively easy to implement, and where adoption can lead to measurable progress.
Yes. Since 2007, our Align. Measure. Perform. (AMP) programs have collected and reported encounter data quality measures. Currently, we use the following measures:
Since 2007, IHA has helped the providers and health plans understand encounter data performance through our Align. Measure. Perform. (AMP) programs. Here are a few significant milestones in IHA’s trajectory: