Fact Sheet

Encounter Data in Medicare Advantage

Medicare Advantage encounter data is intended to capture the details of a Medicare Advantage beneficiary's health and treatment based on "encounters" with clinicians. This data is used to understand the health status of enrollees. 

Key Facts:

• Medicare Advantage encounter data are detailed records about Medicare Advantage enrollees health care.

• CMS uses encounter data to determine and validate payments, as well as to evaluate the MA program.

• CMS has been moving towards greater use of encounter data for payment, but moved back to 15% use in 2018, down from 25% in 2017.

Policy Recommendation:

CMS should ensure a thoughtful transition by delaying the phase-in of encounter data as a diagnosis source until data accuracy and processes are verifiable and reliable. Before moving forward, CMS should work with stakeholders, in a transparent way, to evaluate data, address implementation barriers, and analyze stakeholder impacts to better assure payments are based on accurate risk scores.