Rivet has updated how we calculate expected allowed amounts, improving recode detection and recovered amount accuracy for Payer Performance.
We’ve made important updates to how Rivet calculates the expected allowed amount in Payer Performance Audit. This change impacts how underpayments, recodes, and recovered amounts are handled, leading to more accurate results. Below, we outline the main changes, their implications, and why these improvements matter.
1. Transition to 837 Form Data
We now prioritize fields from the 837 (the claim form) instead of relying heavily on the 835 (the remittance form). This shift includes adopting the procedure codes, modifiers, and units from the claim for our calculations. This ensures that the billed information is the source of truth, aligning better with user expectations.
2. Enhanced Detection of Recode and Underpayments
With this update, we now detect underpayments caused by recodes, where the code returned on the 835 is different from the one billed on the 837. Key bug fixes include resolving issues related to bilateral splits, negative expected amounts, and false variances from re-codes. Other notable improvements are:
Correctly applying bilateral modifiers (50, LT, RT).
Fixing misidentification of denied lines and MPPR (Multiple Procedure Payment Reduction) errors.
Resolving display discrepancies between logic and detail view.
3. New Methodology for Calculating Recovered Amounts
Recovered amounts are now calculated differently across transactions. Instead of relying on variances, we directly calculate the dollar difference between the allowed amounts of the final remit and the first underpayment. Additionally, if a recovery happens on the same day as the original underpayment, we no longer calculate it as recovered, assuming the user did not work the issue.
4. Improved Handling of Corrected Claims
We’ve improved the handling of corrected claims by excluding the claims and remits prior to the corrected claim in our calculations unless there was an underpayment. Rivet now also flags suspected corrected claims when the expected amount differs from the original.
5. Why Does It Matter?
These updates offer users more accuracy by using the claim form (837) as the primary source of truth, reflecting what was actually billed. The detection of re-coded line items as underpayments is a significant enhancement, ensuring issues are identified that might have previously gone unnoticed. This overhaul has also addressed a variety of long-standing bugs, setting the stage for more efficient problem-solving in the future.
If you have any questions, please reach out to our support team via chat or email at support@rivethealth.com