Reconciling Discrepancies on Insurance Payments

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.

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)

Primary Inputs

Contract Allowables by CPT code

Primary Outputs

Contractual variance

Dollar amount of variance

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.