EXL Health and REVELOHEALTH close provider services agreement with national single specialty medical practice

Challenge

A national independent physician organization hired managed care consultants to review their contracts and payments on a Medicare Advantage contract from a large payer. The consultants found that the organization was receiving a less-than-usual percentage of Medicare that was different from the payer fee schedule provided in their managed care contract. They concluded that the organization was being underpaid by using a standard practice management system, a commonly used technology that loads managed care contract allowables within an organization’s revenue cycle management (RCM) system.

Process

The executive team at the physician organization came to REVELOHEALTH and EXL Health seeking a trusted partnership committed to innovation and deep domain expertise in healthcare payments and RCM. They were interested in both RCM services typical to the marketplace and proactive solutions, specifically REVELOHEALTH’s OneCareCost™ point of care repricing solution for providers. Their goal was to implement a solution that eliminated or avoided revenue cycle issues at their start before they manifest downstream and add uncontrollable costs. Together in partnership, powered by the real-time analytics from OneCareCost, REVELOHEALTH and EXL Health agreed to build an optimal workflow and revenue cycle solution customized to meet the organization’s needs for each of its local markets.

Project goal

Validate or invalidate the claim that the larger payer was underpaying their Medicare Advantage claims and, where possible, further identify the payer behavior with corresponding justification dictating the different payment.

Solution

All managed care contracts with the corresponding documents in question were converted into payer rates utilizing REVELOHEALTH’s claims repricing system, a process which constructs the complex rules engine dictating the payer’s calculations. Leveraging technology typically only available to payers, our repricing analysts provided the client with a summary of all contractual discrepancies and the corresponding lower allowable they would generate. Our analysts then reconciled all CPT codes by practice within their practice management system, ensuring all procedure volumes, modifiers, edits, and units were captured. All codes were indexed to local Medicare rates for baseline comparisons as analysts repriced suspected underpaid claims to each managed care contract in use. By function, the OneCareCost platform provided each CPT code’s corresponding allowable modified per the terms and rules of the manage care contract. This was easily reconciled with the supplied fee schedule and amount ultimately paid by the payer for all codes in question.

Initial results

The OneCareCost platform clearly outlined the payer behavior leading to the lower allowables being examined. To the organization’s surprise, the payer correctly paid the bulk of the claims in question. However, our analysts were able to show various contractual adjustments, policy updates and payment rule changes that the payer implemented within the contract term, leading to reduced but accurate reimbursements. The largest such rule update resulted in a large payer changing several affiliates’ Medicare indexes from an urban designation to rural, which reduced allowables for many codes by an average of 30% even though the fee schedule contracted rate remained the same. Given the complexity of these modifiers, the organization’s practice management system, and the managed care consultant’s application, these contractual adjustments were not identified, causing a significant reduction to meaningful portions of their payer mix.

Leveraging human ingenuity, including our advanced information tools, deep domain expertise and knowledgeable resources, EXL Health and REVELOHEALTH allow providers to take meaningful action to avoid costly issues, preventing downstream issues with increasingly expensive resources.

Next steps

The analysts within the REVELOHEALTH and EXL Health partnership are extending the managed care contract payment analysis to all payer products. This exercise will build out verified rate sheets and corresponding rule engines to identify segments degrading the allowable return for all codes where the traditional practice management system relying on payer supplied fee structures cannot. This process will also extend reconciliation of OneCareCost generated allowables to payments identifying reimbursements underpaid with payer rule justification utilized, if applicable.

The above contractual analysis extended to all commercial payer contracts and will continue simultaneously with REVELOEHEALTH’s OneCareCost point of care repricing to immediately alert the provider to a lower allowable amount not supported by the active managed care contract or a new legal amount as dictated by a contractual adjustment. In the event of either alert, the organization will be prompted to take immediate commensurate action, such as a chargemaster adjustment, coding or diagnosis augmentation, patient responsibility communication change or proactive arbitration documentation. By implementing OneCareCost across all payers, the organization will receive full compliance with all known CMS requirements per the No Surprises Act and Price Transparency Order.

The validation of this solution, utilizing payer technology on the provider’s behalf at the point of care, continues to prove beneficial to several use-cases and the client is expanding the partnership to include ongoing revenue cycle workflow assessment, credit balance and A/R resolution, and complete enterprise revenue cycle management suite of services.

Value

Through our partnership, EXL Health and REVELOHEALTH makes sense of data to provide full insight throughout the revenue cycle end to end. Using payment analytics and digital-first payment processing solutions, we partner with our clients to implement collaborative solutions that provide up-front price transparency, improve revenue capture, optimize payment processing operations, and maximize and protect working capital.

The OneCareCost payer claims repricing engine, deployed at or before the point of care, delivers a dynamic payer view of the true allowable in weeks, if not months, before traditional systems would offer a portion of the same information. The OneCareCost payment analysis also offers visibility into underpayments and contractual adjustments with payer managed care contracts that current contract loading modules, contract management systems and reapplied RCM systems are unable to identify due to increasingly complex and dynamic updates throughout the plan year.

Leveraging human ingenuity, including our advanced information tools, deep domain expertise and knowledgeable resources, EXL Health and REVELOHEALTH allow providers to take meaningful action to avoid costly issues, preventing downstream issues with increasingly expensive resources. The REVELOHEALTH and EXL Health partnership is working together to redefine the RCM business in new and automated ways, allowing providers to shift resources back to providing high quality patient care.

Contact our expert team members to learn more

Adam Z. Cohen
Vice President, Provider Accounts, EXL Health
adam.cohen@exlservice.com

John R. “J.R.” Thomas
President & Chief Executive Officer, REVELOHEALTH
jr.thomas@revelohealth.net