Modeler is a tool that allows you to compare current and proposed changes to your fee schedules. It can compare differences by procedure group and procedure code. This can help you negotiate better rates and understand what a new fee schedule means for you.

First, you will need to head over to your account settings:

Then, check to make sure you have a charge master uploaded.

Check if you have a Utilization report uploaded. If you have a feed of your claims into Rivet, this step is optional, since you can now use claims as the source of volume in Modeler.

Open modeler by going to “Contract evaluation > Modeler”.

Click “Create new workbook” in the top right to get started.

Name your workbook.

Choose what you want to compare everything in your workbook to, either an existing fee schedule from your Rivet system, or a combination of CMS baselines.

Select the fee schedule you want to be the reference, and then give it a more descriptive name if you’d like. You can filter by Business Unit and active fee schedules to more easily find what you need.

Select the volume you’d like to use for your workbook. Modeler can support using claims (if you have the Audit tier) or utilization files. If you choose claims, it will default to the last calendar year of claims associated with the fee schedule you’ve selected as the reference.

Once you’ve created the reference, choose what you’d like to add as a comparison. You can choose a fee schedule, or add a CMS baseline.

If you choose fee schedule, it will again default to the same fee schedule you chose as your reference. You can name your comparison something descriptive.

Then, you can make changes to the fee schedule rules as needed to model your proposal.

You have the option to make changes to the volume of the comparison as well. Use this option to accommodate for categories or specific codes that you anticipate increasing or decreasing in volume. You can also make changes to the entire volume—for example anticipating 10% growth across the board. You can also skip this step.

You then have the option to keep adding more comparisons to your workbook.

When you’re done, you’ll land on the main workbook screen.

You have several options to group the rows of the workbook in order to understand the way revenue is affected by each proposal.

When using a grouped view, you can click into any of the categories to explore further:

You can also filter the volume by various properties:

Use the checkbox to filter down to the codes that were added or dropped between comparisons.

Another way to evaluate each comparison is by the CMS effective rate. For every rate in a fee schedule, the workbook turns it into a percentage of the respective CMS Current National baselines, and averages all of those percentages across the comparison. This doesn’t take volume into consideration at all, it is purely a conversion of the rates of the comparison into a percentage of CMS.

Click “Show rules” from any comparison or from the reference in order to see and edit the rules that apply to that comparison.

If the reference and comparison are based on the same fee schedule, differences between the two will be highlighted in blue.

You can change which rules you’re looking at by selecting a different comparison from the left or right dropdown.

You can see which fee schedules the comparisons are based on by hovering over the (i) next to the comparison selector.

You can collapse and reorder comparisons to arrange the view however you want. Both options are found under the options of a comparison.

To save space, collapse a comparison. Click the comparison name to expand it again.

To reorder comparisons, use the arrows in each comparison to move them around, and then click "Save" to finalize the order.

You can choose what columns to show from the Columns menu.

Use the workbook actions in the top right to continue your contract negotiation process.

You can also download the workbook, either the current view (good for the grouped views) or all the data in the workbook.

Comparisons have a variety of actions available.

Modeler has the ability to adjust the revenue by applying certain modifiers, and in the case of workbooks with utilization from claims, provider-specific discounts and multiple procedures discounts.

Enabling the “Apply adjustments” feature will change the revenue to account for modifiers that don’t have a contracted rate, but are conditional and will change the reimbursement when billed.

See which adjustments are applying from “See adjustments” on any comparison.

List of modifiers applied with this setting:

Modifiers with their own fee schedules rates will always apply, since they’re defined in the fee schedule rules.

It is also important to note that this feature is an approximation, and is not to be used in place of net revenue forecasting.

If your workbook is using Claims:

You can edit the volume that any comparison in the workbook is using. This allows you to model projections of how your practice might grow in the upcoming years, hiring of new specialities, or the expansion of specific new CPT codes.

When editing utilization, you have the ability to edit specific volume numbers or increase by a percentage. Modeler will always round to the nearest visit, and never use fractional volume. With procedures that have a smaller volume count, this can result in a different number displaying than was inputted because of the rounding.

If you have any additional questions about Analyze Prospective Reimbursement with Modeler, feel free to chat in or email at support@rivethealth.com.

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