To be set up for success when working underpayments in Rivet these are the recommended steps we suggest for an efficient and accurate way to work through detected underpayments.
Keep the following questions in mind as you read through and follow this workflow:
What are your top priorities or goals with the underpayment tool?
What does success in Rivet mean to you?
How do you currently work underpayments?
Where will Rivet fit into your current processes or workflows?
Who will be the primary underpayment users?
How are you going to roll this new workflow out to your team?
We recommend consistently dedicating 2-3 days a week or more of representatives' time during the calibration part of this process:
📝 Side note: The Calibration Period depending on the size of your practice is typically anywhere from 3-6 months.
Step 1:
Below are some questions to answer BEFORE you start actively working on your detected underpayments. This will help you identify and prioritize which claim line items you want to start working through.
What are my payer's timely filings?
Do I want to appeal everything even claims outside of the timely filing windows?
Is there a variance amount that is not worth the time it takes to appeal?
Are there certain codes that are not worth the time it takes to appeal?
Are there providers you know for certain time frames that are not processed per the contracted rate because they were not credentialed yet?
You will work through each payer and fee schedule. This may seem overwhelming initially, but you can narrow down the list of underpayments into manageable chunks.
Step 2:
Pick a payer and review all fee schedules with underpaid lines:
Once you decide which payer you'd like to prioritize you can start reviewing and validating the detected underpayments.
Start with a payer you already feel might have an issue
Payer with the highest case-mix
Payer showing the highest or lowest amount of underpaid lines
🎆 If you are lost and are not sure where to start don't worry you can click on this article to help you get started 5 Reasons WHY
In addition, you'll want to simultaneously gather the below information.
Find out if you have a provider representative, who they are, and what their contact information is.
Work with the payer and/or provider representative to find out what their policy is around how you should communicate with them regarding mass appeals.
Make sure you understand the follow-up process and what the timeframe will be.
Appeal timeframes can often be listed and/or referenced in the contract.
Step 3:
Decide on a specific fee schedule you want to work through.
This could be the one with the highest number of underpaid lines
Step 4:
Pick a timeframe
To determine the timeframe in which you'd like to filter the detected underpayments you can look at:
Timely Filing
When a payer updates their fee schedule (i.e. yearly, semi-annually, quarterly)
💡 Tip: Once you determine the timely filing timeframe we recommend you move those claims that are too old to be appealed to the rejected status with a note.
Step 5:
Now decide if you want to work the whole fee schedule at one time using the table headers to organize your list.
🎆 If you are lost and are not sure where to start don't worry you can click on this article to help you get started Strategies to help identify false positives and common calibration issues
💡 Tip: Configure the underpayment table to your preferred view to easily show the information you're truly after. For more information on configurable tables, see this article.
Or further narrow down your detected underpayments list even more by utilizing the + Add filter button and custom filters.
Select the + Add filter button and you'll see a list populate of several filters you can apply:
By Line Item
By Claim
💡 Tip: You can create and save your own custom views, for more info check out this article! This will save you time and save the filters you've applied to return back to.
As you are working through your payers you will want to utilize the workflow statuses: Take a look at how you can customize the statuses to better fight your workflow by clicking on this article Custom Status in Underpayments
📝 Side note: Statuses in the underpayments table are there to help keep you organized and optimize your workflow!
💡 Tip: Save yourself some clicks by using bulk actions to change the status, re-assign, record a note, send an email, or export data for multiple line items at once.
Step 6:
Send out your project!
Once you have worked your full fee schedule and/or payer you will take the information you have obtained from the payer about how to work with them regarding mass appeals (pull into CSV, put into the needed format, upload to the website, email to provider rep, or dedicated email) and send your project out.
💡 Tip: You can also assign lines to specific representatives to be worked on.
During the second part of this process we recommend dedicating at least 1 day a week of representatives' time:
After you have worked through each payer to:
✅ Verify that Rivet's data is accurate and up to date
✅ Confirmed the variances are valid
✅ Submitted your projects to the payer
Your workflow will change a little
Now your main job is to follow up with the payers on a consistent basis and bring each project to completion (making sure to keep Rivet’s statuses and notes updated with where your projects are at).
While keeping an eye out for new underpayment projects that might flow into your detected status (these should be much easier to spot now that everything is cleaned up).