Payers Utilize ‘People, Process, Technology’ Framework to Enhance Revenue Capture and Encounters

This is an AArete Healthcare Payer insight

Payers in the healthcare industry are facing a significant challenge due to Medicaid redetermination, which is expected to lead to a decline in revenue for health plans across the United States. This article emphasizes the importance of a comprehensive strategy to ensure that all earned income per encounter is properly collected and reported to minimize revenue loss, especially in the context of managed care. 

Medicaid redetermination is expected to result in the disenrollment of about 15 million Americans, affecting 17.4% of Medicaid and Children’s Health Insurance Program enrollees. This, in turn, will lead to a reduction in Medicaid revenue for approximately 83% of health plans. Additionally, states have become more rigorous in reviewing encounters and imposing higher reporting standards. At the same time, payers may face higher medical loss ratios (MLRs) due to the likelihood of retaining higher-acuity members.

Mark suggests that payers need to refocus on encounters to ensure proper compensation for the services they provide. To tackle this issue effectively, a “people, process, and technology” (PPT) framework is recommended. PPT involves aligning people, processes, and technology to enhance operational efficiency and solve complex business problems. 

Under the PPT framework, it is essential for payers that their teams across various departments understand state regulations, reporting requirements, and their roles in the encounter process. Updating processes and governance systems is crucial to facilitate accurate reporting and efficient data flow. Furthermore, payer technology should be agile to adapt to changing state regulations, with analytical tools designed to identify data gaps and streamline claims processing. 

In conclusion, with Medicaid redetermination impacting healthcare revenue, health plans must take a strategic approach to improve encounter processing and reporting. Doing so will safeguard revenue and operating margins, providing the necessary financial resources to continue offering quality healthcare to members. 

Click here to read the full byline originally published in MedCity news on October 26, 2023. 

Meet The Author

Mark O'Hara

Mark O’Hara

Managing Director