Encounter Data Validation

IPRO staff includes certified auditors, clinical reviewers and other health care experts such as coders, analysts, programmers, database managers and statisticians. Clients can opt to use one, all or any combination of program components, which include:

Encounter data questionnaires.
Assessment of accepted and rejected encounters.
On-site review of systems and processes.
Comparison of encounters to medical records.
Comparison of encounters to transactional data and reports.
Technical assistance.

IPRO medical record-based reviews focus on:

Verifying encounter data accuracy in relation to the medical record -- a standard approach in fraud and abuse review.
Verifying the presence of encounter data for all documented services in the medical record and the completeness of encounter data for all documented diagnostic information.
Confirming the absence of services for members or providers for whom no encounters have been submitted.

As the EQRO for New York, Pennsylvania and Rhode Island, IPRO has conducted numerous studies of Medicaid data accuracy, completeness and quality, as well as national Medicare encounter data projects.

IPRO's staff has extensive knowledge and experience in all mandated, as well as optional, activities outlined in the new External Quality Review (EQR) regulations. IPRO's comprehensive encounter data review and validation program can be customized for each client. The program is designed to help clients develop reliable and complete encounter data to support:

rate development and risk adjusted assignment of reimbursement for chronic illness, as well as other case mix adjustment models;
assessment of utilization and access to care;
assessment of quality of care; and
implementation of performance improvement activities.

IPRO has been performing encounter data review and validation services for nearly 10 years.

For more information about Encounter Data Validation, contact us.