3 things to know about encounter data and providers' potential penalties under Medicaid MCOs

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Providers in Medicaid managed care organization agreements should analyze potential penalties health plans may pass along under encounter data requirements, representatives from Epstein Becker Green wrote in a Lexology post.

Jackie Selby, a member at the law firm, and Gregory Mitchell, an associate at the firm, wrote about encounter data requirements under the Medicaid Managed Care Rule. CMS released the final rule in May 2016, which requires states to gather and retain encounter data from their MCOs for contracts effective July 1, 2017. Encounter data documents provider characteristics, as well as patients' clinical diagnoses and treatments.

Here are three things to know about providers' potential penalties under the requirements.

1. The federal government and several states are tying timely submission of encounter data to federal payments, and requiring state audits of Medicaid MCOs' encounter data. For example, Oregon withholds 1 percent of capitation payments to MCOs pending correct submission of encounter data. 

2. Although federal and state regulations do not pass penalties for untimely submissions to providers, MCO plans may pass submission responsibility, as well as potential penalties, to providers.

"In some instances, existing agreements may already include provisions passing down to providers any penalties that are incurred by a contracted MCO," the authors write. "Even if an existing agreement does not address the submission of encounter data, both providers and plans may desire to address the submission of encounter data issue when they revisit their agreement."

3. As a result, providers and MCOs should determine the responsibility each will take on when issues pertaining to encounter data submission arise, the authors added.

"It is in the best interest of all parties involved to ensure that the entity that ultimately has control over a particular aspect of encounter data (e.g., accuracy, completeness, accurate aggregation, timely reporting), also shoulders the burden of penalties for failing to meet its responsibilities," they wrote.

For the full Lexology post, click here.

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