Hindsight is 20/20, and with the recent EDGE Server deadline having just passed last Friday, May 15, 2015, our Customer Advocates at Infogix had the chance to think about what their Top 10 Customer Lessons Learned over the past year.
Many of our leading customers walked the fine line between being on the leading edge and almost falling over the edge when it came to completing their EDGE Server implementations. Infogix learned much as they assisted customers in implementing new EDGE server solutions, which puts us in a unique position to share the similarities customers experienced.
We all might think we are unique, but many of us went through the same trials and tribulations that are inherent in implementing any new process. Even though many customers worked tirelessly to remain compliant and complete EDGE Server submissions, many underwent stress in working through and trying to resolve the myriad of roadblocks along the way.
So to share some wisdom that is still valuable to further streamline EDGE Server implementations, here is a list of the top 10 lessons learned.
1) Duplicate Claim Monitoring – Duplicate claims are creating chaos, leading to inaccurate and/or rejected data.
Verification of claims within a single submission or across multiple submissions highlights any potential duplicates prior to XML file generation.
2) Enrollment Data Reconciliation – Membership enrollment changes must be reconciled into matching enrollment periods.
For example, if someone has a rate change on 3/1, their original enrollment period is 1/1 – 2/28, then they have a new enrollment period from 3/1 – 12/31. The member cannot have an enrollment period of 1/1 – 12/31, they must have matching enrollment periods.
Automated controls can flag unmatched enrollment periods.
3) Bad Data Prevention – Garbage in equals Garbage out. Data quality issues with the input data increases the rejection rates.
Field-level validation on each record ensures accurate data submissions.
4) Visibility into Complex Information – XML files from EDGE Server are a bear to work with – both in size and complexity.
Visibility through easy to understand reporting is crucial.
5) Acceptance Calculation Certainty – Calculating claims acceptance percentages among claims with multiple submissions is challenging.
Maintaining a history of previously submitted claims and acceptance status allows for tracking and highlighting multiple claims submissions.
6) De-Identified Data Error Resolution – It’s painful to research errors on de-identified data without the original enrollment ID.
A controls solution stores the original enrollment ID as well so mapping the masked ID to actual source is automatic and the error can be researched more quickly.
7) Decoding Error Messages – CMS error messages are hard to decode. It’s taking an exorbitant amount of cost in time and resource to research the root cause of an error.
Automated exception management can quickly route errors of certain types to the appropriate resources to minimize research time.
8) Prioritized Exception Handling – Without exception management, everything seems to be an exception.
An exception management solution integrated with the error reports can help track open issues to ensure resolution, escalate errors are over a certain threshold (e.g., time, dollar amount), and maintain a complete audit trail of resolution.
9) Process Q&A Response – Resolution of questions to CMS are slowing down the process.
Having a technology partner who also understands the process can help respond to changes as resolutions become available.
10) Compliance Readiness – Anxiety over readiness for submissions is keeping Payers up at night.
Infogix provides the confidence that Payers are submitting accurate data to the EDGE Server in order to ensure the most precise Risk Adjustment and Reinsurance calculation results.
With more changes undoubtedly on the horizon, it is always helpful to take a peek back, at what we’ve learned, before forging ahead at what is next to come.