Cutting-Edge Contract Integrity - Guarantee Payers Stick to Terms

iCALIBRATE? is a unique managed care contract integrity or Contract Adherence Rate (“CAR”) solution provided by REVELOHEALTH, LLC?. iCALIBRATE is unique due to its foundation of a payer claims repricing technology versus contract management systems or revenue cycle analytics. By analyzing through the payer’s repricing system from the provider’s managed care contract, iCALIBRATE reduces the cost of collection of healthcare payments for providers and payers by seeking contract adherence in advance of the high cost of traditional revenue cycle management activities.

The value of iCALIBRATE lies in two distinct areas:

First, a provider knows the actual dollar amount allowed under its managed care contract and related insurance products, indexed to site specific Medicare rates. A provider knows dollars the payer pays according to the particular contract in near real time. The provider knows the allowable for each claim at the transaction level. The dollars underpaid or underpriced and the number of claims requiring appeals reduce accordingly.

Second, iCALIBRATE identifies the difference between an underpriced claim or contract issue versus a claim requiring an appeal. Appealing contract issues through traditional revenue cycle management channels is not effective. Contract issues must be resolved through payer provider representatives and other departments inside the payer operations.

Once a provider has a high CAR and Match Rate, any unpaid claims can be resolved through workflow improvements within the Provider’s operations. Workflows around eligibility denials, additional information requirements, and medical review requirements can be optimized within the Provider’s office to reduce the workload to resolve these claims and payments.

Figure 1. Dates of Service January 1. 2022 through October 1, 2022.

Below is an example of iCALIBRATE for a large, multistate physician organization where iCALIBRATE has been live for over twelve months. The first screen indicates claims with dates of services from January 1, 2022, through October 1, 2022. Adjudication dates of January 6, 2022, through November 15, 2023, accounts for all payments. Contract 1A will be analyzed for brevity and Contract1 A was renegotiated effective October 1, 2022, therefore justifying an October 1, 2022, close date.

Key Findings – Figure 1

· Overall, the commercial and Medicare Advantage plans are paying 101% of the contract rate for the period.

· However, only 70% of 205,401 transactions match the contract rate at a 5% threshold of the contract price. Therefore 30% or 60,000 transactions are either underpriced or overpriced to the specific contract price.

· Underpriced claims total $763K that require contract appeal process. $1.2MM of overpriced claims are subject to payer recoupment in future periods, jeopardizing cash reconciliation issues within the provider organization.

· There are significant variances in the CAR (EOB/Contract) and the Charge Count Matched by contract.

· For Payer 1A highlighted above, the contract rate indexed to site specific Medicare is 109%. The payer is pricing these claims at 107% generating a CAR of 98.8% and Match Rate of 49% of transactions at 5% variability.

Key Findings – Figure 2 - New Managed Care Contract

Our Client utilized our mCALIBRATE? solution to determine the actual dollars per code and Medicare index to negotiate a new managed care contract with Payer 1A. For comparison purposes, prices between iCALIBRATE and the payer’s price are held to a 5% variance rate.

· Overall, the CAR rate of 100% shows slight improvement for the period.

· Match Rate of 76% of 308,013 claims is 5% higher than the prior period representing over 15,000 claims that match our iCALIBRATE price and the price allowed by the payer. There are 15,000 claims where the RCM staff do not have to appeal for resolution.

· For Payer 1A, the contract was amended and demonstrated a 5% increase in Payer pricing from 108% to 113%, representing over $225K in new revenues.

· The CAR rate remained consistent with the first year using iCALIBRATE at 98% of dollars.

· However, the Match Rate of claims improved from 49% to over 85%, reducing the claim appeal requirements by over 15,000 claims.

Summary

iCALIBRATE solves two historical problems in the collection of healthcare payments for providers. Our solution differentiates between (i) Contractual issues and (ii) underpayments. When using iCALIBRATE our clients have experienced an increase in contract rates as well as a significant reduction in claims that require claim review and appeal. For one client and one payer, the managed care contract increase represented 5% or $225,000. The improvement in the Charge Count Match Rate reduced the charge count review and appeal rate by over 15,000 charges in the period. Assuming a $10.00 per claim appeal cost, over $150,000 was saved, allowing claim appeal staff to improve workflow to improve the timing of collections and collections overall. Based upon the first-year use of iCALIBRATE, our client was able to improve the traditional healthcare revenue cycle process outcome by over $375,000 for a single payer or 8.3%.

Imagine the impact of iCALIBRATE over two years, every commercial payer, and higher reimbursed claims with outpatient and facility claims...

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