Reconciling Discrepancies on Insurance Payments


Purpose

Reconciling discrepancies between payments from insurance companies and previously contracted rates

Tag(s)

 

Panel

Non-interpretive panel, Business Facing

Define-AI ID

19100005

Originator

Worth Saunders

Lead

Worth Saunders

Panel Chair

Rich Heller

Non-Interpretative Chairs

Alexander J. Towbin, Adam Prater

Panel Reviewers

Business-facing sub-panel

License

Creative Commons 4.0

Status

Public Comment

Clinical Implementation


Value Proposition

The goal is to ensure accurate and complete reimbursement from payors for services provided by radiologists and/or imaging facilities.  

Narrative(s)

Radiology providers (both professional service radiology groups and imaging facilities) have contracts with insurance companies or standardized fee schedules with governmental payors (e.g., Medicare and Medicaid). These contracts establish rates that should be paid to providers when services are provided to in-network enrollees. For various reasons, there are occasionally inconsistencies between the stated rate in the contract and the amount actually reimbursed. It is the responsibility of the services provider to identify inaccurate payments in a timely manner.  Best practice in this regard is to have an active reconciliation process so that any discrepancies between the amounts paid and the actual contracted amounts are identified and addressed.  

Workflow Description

The tool would compare payments based on contracted rates. Payments not meeting criteria would fall into an exception worklist for review. Payments determined to be incorrect would be appealed to the payer for reconsideration and payment corrections. Upon appeal, the charge would be “pended” for a set period to allow for additional payment. Once updated payment received, the tool would re-review and, if payment is now correct, it would no longer be considered an exception and would be removed from the exception list. If payment is still incorrect, the charge will return to the list as an exception to be reviewed. The tool would allow for trending of exceptions to identify larger-scale follow-up needs with payers.


Considerations for Dataset Development


Potential Data Elements: 

Contract Allowables by CPT Code

CPT Codes

ICD 10 Codes

Contract terms (i.e., start and end date)

Date of Service

Technical Place of Service (e.g., Hospital, Physician Office, IDTF)

Facility Location NPI

Radiologist Interpreting Place of Service

Radiologist NPI and Name

Referring Physician Name and NPI

Payor and Employer Group Identifier

Payments by CPT Code

Charges by CPT Code

Modifier

Acceptable variance levels (probably % of allowable- e.g., 3% or below)


Technical Specifications


Primary Inputs

Contract Allowables by CPT code

Definition

The dollar amount of the payment from the payor for each service/procedure (CPT) that is billed as defined in the contract between the payor and provider of service

 
CPT codes

Definition

Current Procedural Terminology (aka procedure codes)

 
ICD 10 codes

Definition

International Classification of Diseases, version 10 (aka diagnosis codes)

Contract Terms 

Definition

Start and end date of contract and descriptions of obligations by each party

Date of Service

Definition

Date service was performed

Technical Place of Service 

Definition

place of service such as hospital, physician office, Independent Diagnostic Testing Facility

Facility location NPI

Definition

National provider identifier of the imaging facility

Radiologist interpreting place of service 

Definition

Hospital Outpatient, Hospital Inpatient, Imaging Center, Physician Office, Home

Radiologist NPI and Name 

Definition

National Provider Identifier and name of Radiologist

Referring physician NPI and Name 

Definition

National provider identifier of referring physician and name

Payor and employer Group Identifier 

Definition

Name of the payor (with product identifier) and employer group Identification

Payments by CPT Code 

Definition

Dollar amount reimbursed by the payor for each CPT code

Charges by CPT Code 

Definition

Gross fees set by the provider for each CPT code

Modifier

Definition

As defined in CPT


Primary Outputs

Contractual variance

Definition

contractual variance.

Data Type

Categorical

Value Set

  • No variance in payment to contract
  • Variance in payment to contract

Units



Dollar amount of variance

Definition

Amount of variance in dollars.

Data Type

Numeric

Value Set

              N/A

Units

Dollars


Future Development Ideas



AI could consider additional rules and contractual carve-outs that need to be considered in this reconciliation. AI should learn from corrections made during the process – i.e., each time a determination is made whether the variance is acceptable or not, the AI tool should learn and incorporate that knowledge into future outputs. AI could also help link quality or other measures to payments in the context of value-based reimbursement methods.  Exceptions can be coded with categories to identify ones that need to be worked and those that don’t.