Managed Care Advisory Group

3434 Granite Circle
Toledo, Ohio 43617

1-800-355-0466
info@mcaginc.com

MCAG is a revenue recovery consulting firm where teams of advisers, auditors, analysts and IT professionals provide expertise, analysis and technology to ensure our clients capture every recoverable dollar.  

© 2018 by MCAG

An Introduction to
Contract Payment Review

Overview

Our Contract Payment Review (CPR) service ensures hospitals and physician groups receive payments that meet all negotiated/contract reimbursement rates.  We focus on under allowed, under billed and denied claims to ensure our clients are capturing every recoverable dollar.  Our expert advice helps to streamline workflows, provides for a faster recovery process, and improves cash flow. 

This online guide contains helpful information for getting the most out of our CPR solution.  We are looking forward to working with you.

What to Expect

Our CPR process can be broken down into three simple steps: (1) implementation, (2) analysis, and (3) appeals & recovery. Each of these steps consist of several sub-steps outlined below:

DATA LOADING

Data loading and verification can take up to 2 weeks depending on volume. Many of our clients depend on clearing houses for their data and some supply it to us directly through our secure process.

FEE SCHEDULES & CONTRACT REVIEW

This step begins as soon as the contracts and fee schedules are received by MCAG. The review process takes about two weeks. 

ANALYSIS

Once MCAG has the data and the results of the contracts and fee schedule reviews, the analysis begins using our proprietary AMS to develop our CPR reports. Depending on the size of the report, it typically takes 3 - 4 days per report. 

RECOVERY

We usually begin to realize recoveries within six months of completing the data loading and fee schedule & contract review. 

Within a few days after we receive a signed contract, your MCAG account manager will make an introduction and set up a kick-off call with your team.  During this call we will review our implementation process, CPR workflow and discuss your payer contracts and payer volumes. We'll also begin setting up the process for securing your data files (ANSI 835/837) from your clearinghouse or from you directly, as soon as possible. The data is crucial to the review process and will drive the analysis and reporting.  We will not be able to begin the analysis until we have access to your data, contracts and fee schedules.

What We Need from Your Organization
  • Data – ANSI 835/837 Payment and Remit records. We can receive this data directly from you or from your clearinghouse. If we are managing denials, we'll want to receive the data on a daily feed. CLICK HERE FOR DETAILS ON THE DATA REQUIREMENTS.

  • Contracts – We will need copies of your original payer contracts along with any amendments and attachments.

  • Fee Schedules – We will need to see any proprietary fee schedules that are not solely based on CMS rates.  Examples include the Aetna Market Fee Schedule or the Cigna Standard fee schedule.  If it is based on CMS, we will create/model those fee schedules.

  • Physician Lists/Provider Rosters – This information needs to include all TINs, group and individual NPIs, provider specialties, and locations, as well as their start/end dates.

  • Payer Matrix/Payer Library – This helps us to map the payers to the data correctly and provide the most comprehensive review possible.

  • Payer Volume – This can be the average number of billed claims by payer for a specific time frame.  This helps us understand the size of the data that will need to be processed and stored.  It will also help us to determine your larger payers.

  • Access to payer websites such as Navinet or Availity – This helps us to efficiently review and appeal claims on your behalf.

  • Access to your practice management system – This helps us to review individual claim issues and reduces any time that we might need to ask questions of your staff.  Sometimes a claim can have adjustments to the charges, or an insurance change that is much easier to identify in the practice management system rather than in the data.
     

What We Do with What You Give Us

  • Data – The 835/837 files are imported into our AMS.

  • AMS – Behind the scenes the AMS scrubs, sorts, and filters the data to prepare it for report generation.

  • Mapping – This is where your payer matrix or payer library comes in.  We must tell the AMS how to match up all the different payer names that are identified in the data.  This way we make sure we are matching up the correct data with the correct contracts and fee schedules.

  • Report Generation – The AMS generates reports categorizing the claims into under allowed, under billed, and denied claims for review by MCAG. The MCAG CPR Team reviews the claims reimbursement for modifiers, multiple procedure reductions, plan anomalies, location differences as well as credentialing specialties to validate the analysis report results. The MCAG CPR Team then imports the findings into the AMS populating the CPRvista Dashboard. Those results are discussed with you and an actionable plan is created to capture every recoverable dollar.
     

Once we have the data elements and contract and fee schedule information loaded into our Audit Management System (AMS) we'll begin the process of identifying any variances between your contract reimbursement language, the fee schedules, and the processing of your claims. The variances will be viewable in our CPRvista dashboard and will be reviewed with you to help you utilize the information for recovering any funds due, and to correct any systemic issues with the payers.

 
So How are CPR Findings Categorized?

Our findings are focused on three categories of submitted claims:

  • Under Allowed

  • Under Billed

  • Denials

Let's take a deeper dive into each of these three categories.

 

Under Allowed: In our experience we find three main types of under allowed issues in our reviews: 

  1. Systemic Issues – these issues are complex issues and usually have to do with the way the provider or fee schedules were loaded into the payers' systems.  These issues are usually long term type under payments.  We pursue these recoverable claims back to the time of their inception or as far back as the law allows.  Usually multiple years are involved, and we follow this issue through the entire time frame involved.

    1. Credentialing Issues – these are more provider specific issues.  A provider is set up incorrectly within the payers' system.  Their claims may be allowing at a mid-level rate instead of an MD. Or they may be receiving payment based on a PCP fee schedule rate, but they are a specialist.  We work with your payer to get the provider corrected and a rework project created for all of the effected claims.

    2. Contractual Issues – these issues are typically found when a fee schedule yearly inflator was not implemented timely or not at all.  It is also commonly found when multiple percentages of CMS RBRVS are utilized within a fee schedule.  We work with your payer to create a rework project to capture all of the recoverable funds available to you.

  2. Billing Issues – These issues are usually found in coding errors.  They are not usually found over a long period of time and can vary from biller to biller.  We work with you to identify the issues and advise solutions to maximize future recoveries.

  3. Miscellaneous – These issues are usually minor, one or two off type claims that do not seem to have any reason behind their variance.
     

Under Billed: This category occurs when the billed charge amount is less than the contractual allowed amount.  The payer allows for the lesser of the billed charge or the contractual allowed amount.  We identify these situations and make sure you are aware of these codes and the corresponding dollar amounts. This will allow you to make appropriate decisions in regarding to possibly raising your billed charge amount to maximize your reimbursements. 

Denials: We breakdown the denials based on the reason codes into three categories.  Those categories are Recoverable, Needs Review, and Not Recoverable. We are flexible in how we follow up on denials for you based on your needs.  Some clients choose to allow us to work their denials on a 30/60/90 day out process. Others prefer that we only work denials on zero balance accounts.  Either way is fine, we just need to make sure we define your preference during implementation. 

We define these categories as:

  1. Recoverable – these are denials in which a billing error may have been made and a corrected claim needs to be resubmitted. Or some type of standard additional information is requested on the claim.

  2. Needs Review – these denials are more likely an appeal would need to be made in order for the claim to be paid.

  3. Not Recoverable – these denials are not likely to be reimbursed at all.  They may be duplicate claims, or claims in which the benefits have been maximized.

When Will We See Some Results? 

There are several variables that effect how long the CPR process takes. On average though, it usually takes about 90 days to start seeing findings in the CPRvista Dashboard.

Typical time frames for key aspects of the CPR process are outlined below: