Revenue Cycle Time Line:  Payment Discrepancy Processing

This article has links to allow easy access time line content from Scheduling to Bad Debt Recovery.  Use this information as a starting point for planning, SWAT Analysis, or to review policies and procedures for gaps.  Create a time line for your facility to assure all participants share the same expectations.

Goals:

· Assure internal claim processing includes appropriate codes and modifiers for services performed

· Assure reimbursement from Managed Care payers meets the terms of the contracts

Activities and Considerations

The payment compliance team works very closely with personnel involved in contracting managed care agreements, billing, follow up, payment posting and credit balance processing.  Communication and coordination of efforts is critical to assure appropriate reimbursement for services provided.

Periodic audits should be planned to help detect processes that need to be changed to improve billing codes that lead to appropriate payment

Daily Operation

Managed Care Management software reviews all payments received for compliance with final amounts due.

All payment shortages greater than $100 are reviewed and categorized for follow up or appeal within 10 business days of primary payer payment. 

· Shortages between $100 and $999 are consolidated and summarized for quarterly (settlement) meetings with payers.

· Balances greater than $999 are appealed individually

Process and Automation Support

Each day (or week) automation tools should be executed to review all transactions received on primary payer remittance for the previous period.  This review will generate a list of accounts that are potentially “short pay” accounts.  A Managed Care Payment Analyst reviews the accounts to determine the nature of the payment shortage, indicating possible contract modeling errors and payer adjudication errors, classifying the latter into work categories.

Note:  Some software considers the primary payment “on its own”.  Others consider the residual patient balance, the amount of contractual adjustment, any line-item or claim-level adjustments, and partial denials to reduce false discrepancies.

After the initial classification by the analyst, the modeling system must have the ability to “track” potential recoveries from managed care payers.

Appeal letters are generated from form letters, allowing the user to modify the letter before printing the letter and supporting documentation for the appeal.

Letters may also be generated to inform patients of activity and whether it may affect their final balance.

Performance tracking and Management Reports

· Accounts with payments that have not been reviewed

· Accounts that billed after the contractual billing time

· Accounts that primary payment aged beyond the contractual payment window

· Primary payments reviewed (by date, by user)

· Consolidated Appeals By User

· Appeals By Payer

· AR pending by Payer

· Recoveries by User

· Recoveries by Payer