Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Encounter Data.


Anothertool that was frequently mentioned as being essential to quality monitoring and other administrative oversight is the collection and analysis of claims/encounter data. These administrative data contain a record for each service provided by the provider. Every study state requires plans to submit encounter data, and most use the data both for quality monitoring and rate setting. The art and science of maintaining and using good encounter data has evolved over the past decade to the point where most study states are now confident that their encounter data provide useful information for program management and quality oversight of plans. States are increasingly analyzing the data internally, rather than solely relying on the plans to analyze the data and provide aggregate reports.

However, encounter data still have limitations in completeness and accuracy. There are three critical factors that contribute to how complete a state’s encounter data will be. First, when plans use "sub-capitation" (paying providers a capitated rate) there is less incentive for the provider to submit complete data, leading to underreporting. A second critical factor is whether encounter data are used in setting capitation rates. When plans are paid a higher rate when they serve a sicker population (as judged from encounter data), the data will be more complete. A final important factor is the level of experience the plans have with managing encounter data. More years of experience with collecting and reporting encounters improves the chances that an MCO will have the structures and incentives in place to ensure data quality.

States have found that they must continually monitor the quality of encounter data and provide feedback to plans, and they are becoming more sophisticated in how they do the monitoring.

It takes 1–3 years to master reporting encounters to the state. (State Official)

Two of three CEOs came in to meet with us specifically about the methodologies for how we collect our data and how we report the data, and that resulted in them applying appropriate resources, making sure their data and encounters were correct, and really paying attention to detail. (State Official)

One of the things we found is that they [the health plans] could send data, but it was missing key components, and there wasn’t a good process of ensuring that it got corrected and resubmitted. We put in a front-end editing system that can deny claims individually that come in. (State Official)

View full report


"rpt.pdf" (pdf, 1.42Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®