Encounter Data Validation: Review and Project Update

Encounter Data Validation:Review and Project Update

Presenters: Thomas Miller, MA Executive Director, Research and Analysis Team

Amy Kearney, BAAssociate Director, Research and Analysis Team

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Welcome

About the presenters Rules for engagement Presentation overview

• The importance of encounter data • CMS protocols• Florida EDV study, including best

practices for medical record procurement

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Objectives

1. Learn why Encounter Data Validation studies are important.

2. Identify the core evaluation components outlined in CMS’ protocols for validating the quality of encounter data.

3. Review status of Florida Medicaid’s Year One encounter data validation study. Discuss best practices for medical record procurement.

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Importance of Encounter Data

Accurate and complete data are critical to success of managed care programs

Essential for overall management and oversight of Florida’s Medicaid program– Ability to monitor and improve quality

of care– Establish performance measures– Generate accurate and reliable reports– Obtain utilization and cost information

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Importance of Encounter Data

Used by MCOs and the State for many purposes– Performance measure development and calculation– Performance improvement measurement– Focused studies/quality activities– Rate-setting– Compliance monitoring– Provider practice patterns

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Key Trends

Importance of Federal and State monitoring– Development of core measurement sets

• Medicare versus Medicaid• Health care reform• Holding health care accountable

Data, not anecdotes

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Objectives




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Objectives




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EQR Protocol Developed and refined with the evolution of the

External Quality Review program

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EQR Protocol

Guidelines for External Quality Review Organizations (EQRO) to use when assessing completeness and accuracy of encounter data.

Data submitted by Managed Care Organizations (MCO) to the State

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EQR Protocol

State establishes standards for encounter data

State must establish the following standards:– Definition of “encounter”– Types of encounters – Data accuracy and

completeness– Objective standards for data

comparison

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EQR Protocol

Five key activities1. Review state

requirements2. Review MCO’s

capability3. Analyze electronic

encounter data4. Review of medical

records5. Submission of findings

and recommendations

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EQR Protocol Attachment A: Encounter Data Tables

Table 2: Data Element Validity Requirements

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EQR Protocol

Five key activities1. Review state requirements

• Develop understanding of State-specific policies and procedures for collecting and submitting encounter data

• Identify data exchange protocols and layouts• Evaluate encounter data system interchange

flows, including system edits and submission timelines

• Review existing encounter data quality activities, requirements, and performance standards

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EQR Protocol Five key activities, continued

2. Review MCO’s capability• Develop, conduct, and review MCO’s

Information System Capabilities Assessment– Identification of IS vulnerabilities

• Key informant interviews

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EQR Protocol

Five key activities, continued3. Analyze electronic encounter data

• STEP 1 - Develop data quality test plan to determine:

– Magnitude and type of missing encounter data

– Overall data quality issues– MCO data submission issues

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EQR Protocol


• STEP 2 - Verify integrity of encounter data– Macro-level analysis– Encounter file completeness and

reasonableness» Volume and utilization by encounter type and

service setting» Internal field consistency» General field completeness and validity

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EQR Protocol


• STEP 3 – Generate and Review Analytic Reports– Micro-level analysis– Encounter record completeness and

reasonableness

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EQR Protocol


• STEP 4 – Compare findings to state-identified standards– Identification of appropriate benchmark

population

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EQR Protocol

Five key activities, continued4. Review of medical records

• Verification of the accuracy of coding• Protocol assumptions• STEP 1 – Determine sampling for medical record

review– Identify valid sample size– Encounter- vs. recipient-based samples

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EQR Protocol

Five key activities, continued4. Review of medical records

• STEP 2 – Obtain and review medical records and document findings– Procurement efficiencies– Abstraction staff and training– Categorization of errors by level, type, and

source– Procurement tracking and abstraction tools

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EQR Protocol

Five key activities, continued5. Submission of findings

• Narrative report summarizing findings from Activities 1-4

• Actionable recommendations for overall encounter data quality improvement

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Whatcha talkin’ about?

Questions?

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Objectives




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Objectives




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SFY 2013-2014 Encounter Data Validation (EDV) Study

Agency for Health Care Administration

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VALIDATION OF ENCOUNTER DATA

Year One Encounter Data Validation (EDV) Study

Four key steps for conducting successful evaluations– Project implementation– Study design– Data collection &

analysis– Reporting &

recommendations

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Study design– Prepared and finalized methodology which included:

• Study objectives and research questions• Data source and collection procedures• Measurement methodology • Analytic methods• Timeline

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Data collection and analysis– Information systems review

• Questionnaire for AHCA– Assessment of AHCA’s policies and procedures for

data exchange, its capacity and ability to acquire and process data, and its staff responsible for executing data processing

• Questionnaire for MCOs– Assessment of MCOs’ claims processing systems

and processes, and its capability to submit encounter data

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Data collection and analysis, continued– Information systems review

• MCO questionnaire divided into five sections:1. Submitting Encounter Data to AHCA2. Handling Submission Information from AHCA3. Encounter Data Submission from Capitated

Providers 4. Processing and Submission of Medicare Crossover

and other Third Party Claims5. Policies and Procedures in Processing Payment

Information

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• AHCA questionnaire divided into three sections:1. Data Exchange Policies and Procedures2. Data Submission Processing Procedures and

Personnel 3. Encounter Data Processing within the Florida

MMIS

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• Documentation will be used to assess encounter data quality• Questions target how data moves through AHCA’s data

systems and how the MCOs prepare data files for submission

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What has been completed?• Questionnaires were approved by AHCA and

distributed to AHCA and the MCOs • Received completed questionnaires from AHCA and

MCOs

What needs to be completed?• Currently reviewing responses from AHCA and MCOs• May conduct additional follow-up for clarification

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Questions?


Data collection and analysis, continued– Comparative data analysis of AHCA and MCO

encounter data• Evaluates the extent to which encounters submitted by

MCOs to AHCA are accurate, complete, and reasonable– Included all claim/service types—i.e.,

inpatient/outpatient, physician visits, dental, and pharmaceutical

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Data collection and analysis, continued– Comparative data analysis of State and MCO

encounter data• Indicators to measure degree of completeness and

accuracy for each encounter type– Overall record matching—percentage of state

encounters present in MCO files– Field-level matching—percentage of state

encounters with exact value match in MCO file for each select data element

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Data collection and analysis, continued– Comparative data analysis

What has been completed?• Distributed data submission requirements documents to

AHCA and MCOs • Conducted technical assistance sessions with MCOs on

9/16 & 9/17/2013• Received, processed, and loaded encounter data

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Data collection and analysis, continued– Comparative data analysis of State and MCO

encounter data

What needs to be completed?• Conducting preliminary file review

– Ensuring files are sufficient for processing– Completing basic checks

• Generate comparative analysis tables and figures for final report

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Phew… Questions?

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Data collection and analysis, continued– Medical record review

• Represents the “gold standard” • Evaluation of service level accuracy

and completeness• Methodology developed:

– Only includes MCOs operational as of January 2013– Year One – SFY 2016: review one-third of plans each

year as selected by AHCA– Minimum 50 cases reviewed per plan – Target professional, dental, and inpatient/outpatient

encounters

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• Sample selection methodology1. To generate list of randomly selected encounters for

medical review, HSAG will use AHCA’s data files from comparative analyses

2. Two-stage stratified sampling design used to ensure:» Member’s record is selected only once» Number of encounters included in final sample covers

all encounter types and proportional to total distribution of encounters

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• Sample selection methodology– HSAG will evaluate the key data elements below:

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Key Data Elements for Medical Records Review

Key Data Fields DentalInpatient/Outpatien

tPhysician

Date of Service √ √ √Diagnosis Code √ √CPT/CDT/HCPCS Code/ Surgical Procedure Code

√ √ √



• Procurement and abstraction process– Based on established policies and procedures– Continually monitored to ensure validity and

accuracy» Inter-rater reliability testing & Rater-to-

standard testing» All reviewers must achieve 95% accuracy rate» Variety of reports will be generated, i.e.,

medical record compliance rates

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Data collection and analysis, continued– Medical record review – analysis of cases

• Verify the service(s) provided on selected data of service and one additional date of service

• Each enrollee listed on sample has corresponding selected date of service

• Validate services conducted by provider on date of service as compared with encounter data

• Reviewers to validate services for additional date of service.

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Data collection and analysis, continued– Medical record review – analysis of cases

• Analyze record completeness and the accuracy of coding• Four primary indicators for data completeness and

accuracy1. Medical Record Agreement2. Medical Record Omission (surplus)3. Encounter Record Omission (missing)4. Erroneous

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What has been completed?– Introductory letter sent to MCOs on 10/1/13– Conducted technical assistance calls with all

participating MCOs on 10/16 & 10/18/13

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What needs to be completed?– Pull samples and send lists of study cases – Provide letter to send to its providers with sample– MCOs will procure records from provider and

accommodate various submission methods– MCOs to submit identified medical records to HSAG

for review

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Reporting and recommendations– Prepare aggregate EDV report of findings from:

• Information system review• Comparative Analysis• Medical Record Review

– Preparation of supplemental findings for future evaluation by MCOs

– Present statewide and MCO-specific results– Actionable recommendations for improvement

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Objectives




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Questions

Documents

Encounter Data Validation: Review and Project Update