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.