How VIDACounter™ Can Help With New CMS Encounter Data Updates

The Centers for Medicare & Medicaid Services (CMS) constantly refines its guidelines to improve healthcare reporting and transparency. One of the most recent challenges involves ensuring accurate submissions of supplemental benefits data as part of CMS encounter data requirements.

In this article, we’ll explore the new CMS encounter data updates related to supplemental benefits submission, discuss the specific system enhancements and code changes introduced, and explain how Invidasys’ VIDACounter™ can help you navigate these challenges before critical deadlines arrive.

The Growing Importance of Supplemental Benefits in Medicare Advantage

Supplemental benefits, services and items not traditionally covered under Medicare, have become a cornerstone of many Medicare Advantage plans. These might include dental care, vision exams, hearing aids, wellness programs, transportation to medical appointments, or even in-home support services. By offering supplemental benefits, health plans can differentiate themselves, attract enrollees looking for added value, and address specific healthcare gaps in the senior population.

Shifting Demographics: With an aging population that desires comprehensive coverage, MA plans have begun to incorporate a broader range of supplemental services.
Regulatory Encouragement: CMS has increased flexibility around what qualifies as a supplemental benefit, leading to innovative programs that better meet beneficiary needs.
Competitive Landscape: As more MA plans offer supplemental benefit packages, the competition for enrollment intensifies. Providing (and accurately reporting) these benefits becomes essential not just for compliance, but also for maintaining a competitive edge.

Why CMS Is Updating Encounter Data Requirements for Supplemental Benefits

Although supplemental benefits are not standard under Original Medicare, they have become indispensable in the Medicare Advantage ecosystem. To better align payment with actual service usage, CMS needs accurate data on how these services are utilized:

Improved Data Accuracy: CMS wants to capture the full scope of services provided to Medicare Advantage enrollees.
Payment Integrity: Accurate reporting of supplemental benefits helps calibrate payments more precisely, reducing the risk of overpayments or underpayments.
Transparent Quality Measures: Comprehensive data submissions allow for more accurate quality assessments, enabling CMS to see how supplemental benefits influence patient outcomes.

Overview of the Latest CMS Encounter Data Updates

Let’s break down the most critical elements of the new CMS encounter data updates:

Submission Requirements Under 42 CFR 422.310

Medicare Advantage organizations must submit encounter data for all items and services rendered to their enrollees, including supplemental benefits. These requirements aim to ensure comprehensive reporting that captures the entirety of the enrollee’s care experience.

System Enhancements and Submission Instructions

CMS has updated instructions to accommodate supplemental dental services in the X12 837D 5010 format, effective September 13, 2024. This modification allows MA organizations to submit dental claims more seamlessly, reducing errors and delays in processing.

Supplemental Benefit Services Category (SBSC) Codes for Contract Year 2025

CMS has introduced revisions to SBSC codes to ensure that each supplemental benefit is accurately categorized. These codes serve as the backbone of data reporting, dictating how benefits are recognized, processed, and reimbursed.

Data Monitoring and Compliance

CMS will actively monitor submissions and may reach out to organizations not reporting the expected volume of supplemental benefits. This move emphasizes accountability and encourages organizations to remain vigilant about the data they provide.

Common Challenges Facing Medicare Advantage Organizations

Despite the urgency, many health plans find themselves ill-prepared to meet the new CMS encounter data requirements for supplemental benefits. Let’s explore some of the leading challenges:

Legacy Systems and Data Silos

Many organizations still operate with outdated technology, or they rely on multiple platforms that do not communicate effectively. Encounter data may be stored in disparate systems, causing duplication and errors.

Lack of Standardized Processes

Even within a single organization, different departments may have separate workflows for capturing dental claims, vision services, and other supplemental benefits. Without standardization, ensuring accuracy across these varied processes can be an administrative nightmare.

Complex Code Updates

Updating SBSC codes to reflect the new categories for the 2025 contract year requires careful mapping between internal coding systems and CMS’s revised guidelines. If organizations fail to accurately adopt these new codes, they may face delayed or rejected submissions.

Compliance Pressure

CMS has made it clear that it will monitor the submission of supplemental benefits data. Plans that do not comply risk penalties, reputational damage, and possible interventions from CMS.

Evolving Regulatory Landscape

CMS guidelines are not static. They evolve over time, responding to changes in healthcare delivery and legislative mandates. Maintaining constant readiness for regulatory shifts adds another layer of complexity, especially for organizations already juggling multiple priorities.

The Consequences of Non-Compliance

Failing to meet these new guidelines can have dire consequences, including:

Financial Penalties: CMS may impose fines or adjust plan payments if the encounter data fails to meet the required standards.
Operational Inefficiencies: Rejected or delayed claims can lead to backlogs, increased administrative labor, and cash flow disruptions.
Damaged Reputation: A public compliance issue can erode trust among beneficiaries, providers, and partners.
CMS Intervention: In extreme cases, CMS can implement corrective actions that may include oversight or additional reporting requirements.

Introducing VIDACounter™: A Cloud-Based Encounter Data Management Solution

VIDACounter™ is a revolutionary cloud-based encounter data management platform designed to help Medicare Advantage plans efficiently process and submit encounter data for Medicare, Medicaid, TRICARE, and Public Exchange lines of business. It stands out for its ability to achieve a first-pass clean rate of over 95%, drastically reducing the likelihood of rejections or delays.

Rapid Integration and Implementation

VIDACounter™ is engineered for quick deployment—health plans can integrate this solution in as little as 30 days. This rapid rollout allows organizations to stay ahead of regulatory deadlines, ensuring compliance before CMS tightens its monitoring.

Automating Validation and Compliance Checks

Manual validation processes can be tedious and prone to human error, especially when dealing with new codes or formats like X12 837D 5010 for dental submissions. VIDACounter™ employs automated workflows that validate each encounter prior to submission.

Handling Multiple EDI Encounter File Types

From dental claims (837D) to medical claims (837P or 837I), VIDACounter™ supports multiple EDI file types. This flexibility is critical for Medicare Advantage plans offering a diverse range of supplemental benefits.

Business Workflows for Reduced Rejections

VIDACounter™ includes a suite of built-in business workflows that catch common errors and inconsistencies. With supplemental benefits, especially new offerings that might be unfamiliar to staff, these workflows make sure each data point is mapped correctly, coded accurately, and aligned with the latest SBSC code updates.

Take the first step toward simplified operations and airtight compliance with VIDACounter™ by Invidasys. Our experts will guide you through every phase of implementation.

Our VIDACounter™ Suite

Navigating the New SBSC Codes with VIDACounter™

One of the most complex aspects of the new guidelines is integrating the updated SBSC codes for contract year 2025. These codes categorize various supplemental benefits so that CMS can accurately track and reimburse services. Here’s how VIDACounter™ helps:

Automated Mapping: VIDACounter™ automatically maps internal plan codes to CMS’s updated SBSC codes, minimizing manual intervention and the risk of human error.
Real-Time Updates: The platform is designed to incorporate code changes quickly, ensuring your organization remains current with any new directives from CMS.
Validation at Each Step: VIDACounter™ runs validations that check for code mismatches or omissions, guiding users through corrections before final submission.

Staying Compliant with Evolving CMS Requirements

Compliance is not a static goal, especially when dealing with Medicare Advantage. CMS frequently revises submission instructions, code sets, and timelines. Plans must be agile enough to pivot whenever new guidelines appear.

Built-In Flexibility

Whether CMS introduces new data fields, modifies existing requirements, or introduces additional categories of supplemental benefits, VIDACounter™ can adapt through modular updates. This agility empowers your organization to remain compliant without prolonged system downtime or expensive custom development.

Real-Time Monitoring and Alerts

VIDACounter™ includes alert systems that inform users of potential discrepancies or new guidelines that may affect encounter data submission. This real-time monitoring approach keeps you ahead of compliance issues rather than reacting after a submission is rejected or flagged by CMS.

Audit Trails and Reporting

VIDACounter™ maintains comprehensive audit trails, detailing every step of your data submission process. Whether you’re preparing for an internal quality check or responding to a CMS inquiry, these records provide transparency and peace of mind.

5 Practical Steps to Implement VIDACounter™

For organizations ready to adopt VIDACounter™, here’s a blueprint for a smooth transition:

Assessment: Begin with a comprehensive review of your existing systems, data flows, and encounter submission processes. Identify areas that need immediate attention.
Integration Planning: Work with Invidasys to establish a clear integration roadmap, including timelines, resource requirements, and success metrics.
Configuration and Testing: Once integrated, configure VIDACounter™ to match your organization’s unique needs—particularly around SBSC codes and the 837D format. Conduct thorough testing to ensure smooth data flow.
Staff Training: Provide targeted training on VIDACounter™ functionalities. Emphasize the platform’s automated checks to reduce manual burdens and highlight key features that will simplify daily operations.
Go-Live and Ongoing Support: After final validation, move to full-scale production. Invidasys offers ongoing support to address any post-implementation questions, ensuring continuous compliance and process improvements.

Overcoming Organizational Resistance

Introducing a new platform often encounters resistance, particularly if staff are accustomed to legacy systems or manual processes.

Explain the Benefits: Emphasize how VIDACounter™ reduces administrative burdens, speeds up claims, and minimizes compliance risks.
Involve Key Stakeholders: Include input from department heads, IT, compliance officers, and frontline staff to ensure the system meets everyone’s needs.
Offer Training Resources: Provide accessible, ongoing training and documentation. The easier the system is to learn, the quicker staff will embrace it.

5 Best Practices for Staying Ahead of CMS Changes

Even with a reliable solution in place, organizations should adopt best practices to remain proactive:

Regular Policy Reviews: Keep track of CMS announcements, rule changes, and official guidance. Assign a compliance officer or a dedicated team to monitor these updates.
Frequent Data Audits: Periodically review submissions for accuracy and completeness. Identifying minor issues early prevents them from escalating into costly mistakes.
Engagement with Professional Networks: Join industry groups, attend conferences, and participate in webinars. Networking with peers can offer valuable insights into how others are interpreting and handling new guidelines.
Ongoing Staff Education: Make sure staff remain updated on the latest regulatory requirements, especially those that affect encounter data submissions.
Leverage Analytics: Use data analytics to track patterns in supplemental benefit usage, identify anomalies, and refine your submission strategies over time.

Invidasys Tailors VIDACounter™ for Your Systems

At Invidasys, we believe every health plan deserves a solution that integrates effortlessly into its existing ecosystem. That’s why we’ve designed VIDACounter™ to be highly flexible, scalable, and easily configurable for a wide range of operational requirements. Our dedicated team collaborates with you to understand your workflows, data structures, and compliance needs, tailoring VIDACounter™ to address your organization’s challenges. Get in touch today!