Recoupments March 8th, 2018 Trevor Abeyta Rates Operations Section - PowerPoint PPT Presentation

Remittance Advices and Recoupments March 8th, 2018 Trevor Abeyta Rates Operations Section

Our Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources

Purpose of Presentation 1. Why claim and capitation adjustments occur 2. Learn about recoupments 3. Determine if a remittance advice has had a recoupment 4. Questions

Types of Adjustments Claim Adjustments • Capitation Adjustments •

Claim Adjustments Why do claim adjustments occur? • System changes and configurations • Annual legislative rate changes • How do claim adjustments work? • Entire claim is taken back and then repaid with any changes in • reimbursement if they occurred

Capitation Adjustments Why do capitation adjustments occur? • Per Member Per Month Attribution Reconciliation • How do capitation adjustments work? • Capitations are not claims based • Entire capitation is taken back •

Recoupments Adjustments resulting in recoupments will take money back • until the AR balance is satisfied Claims based recoupments can cross into capitation/PMPM cycles • Capitation based recoupments can cross into claim cycles • Systems change request to align recoupment with the type of • financial cycle

Example 1: Claims Cycle

Claims Paid Line • Claims paid which were billed this cycle

Claim Adjustments Line • Claims adjusted from previous cycles

Total Claims/Claim Payments Lines • Total amount paid from the current and previous cycle after adjustments

AR Section • Current Cycle: Total claim adjustments from the current cycle • Outstanding From Previous Cycle: Recoupments from previous cycles

Net Payment/Earnings Lines • Total amount for claims billed this cycle minus any claims adjusted this cycle.

Claim Adjustments Section • Amount being adjusted from the current cycle

Example 2: Capitation Cycle

Capitation Payment Line • Attributed member PMPM paid this capitation cycle

AR Section • Non-Claim Specific Line: Capitation/PMPM Adjustments • Claim Specific: Outstanding AR from Claims Cycle • Important if claims recoupments ran over into the capitation/PMPM cycle

Capitation Net Payment/Net Earnings Total amount paid this capitation cycle minus any • capitation adjustments and leftover claims adjustment ARs

Financial Transactions

Financial Transactions • A/R Number Ranges • 350000000 – 499999999 – Physician Claim Adjustments • 700000000 – 799999999 – Capitation Adjustments • Remember: Capitations not claims based • Capitations do not have ICN Numbers

AR Number Ranges 000000000 – 099999999 – Manually created ARs • 100000000 – 249999999 – UB92 Claim Adjustments • 250000000 – 349999999 – Dental Claim Adjustments • 350000000 – 499999999 – Physician Claim Adjustments • 500000000 – 699999999 – Pharmacy Claim Adjustments • 700000000 – 799999999 – Capitation Adjustments • 800000000 – 899999999 – Incentive Adjustments •

Helpful RA Tips If Check/EFT is all zeros no financial • transaction was made

Helpful RA Tips • If the first total recoupment line is a larger number than the second it is likely a runover AR Balance from a previous cycle

Questions?

Contact Information Any additional questions please contact: Corey Wong Business Analyst corey.wong@state.co.us Trevor Abeyta Rates Analyst trevor.abeyta@state.co.us

Thank You