False positives are when Rivet identifies an Underpayment and or Overpayment but it is being tricked by something and the claim line is actually paid correctly. During your calibration period, you will work through these false positives helping our Riveters to further customize your account for your payers and providers relationship.
If you are lost and are not sure where to start don't worry this article is to help you get started.
1. Pick a payer and review all fee schedules with underpaid lines: (if needed click on this article to get a few ideas 5 Reasons WHY)
Once you decide which payer you'd like to prioritize you can start reviewing and validating the detected underpayments. If you are not sure how to decide on a payer below are a couple of suggestions to consider.
Payer, you already feel like might have an issue
Payer with the highest case-mix
Payer showing the highest amount of underpaid lines
Medicare (they typically do not underpay)
2. Decide on a specific fee schedule you want to work through.
This could be the one with the highest number of underpaid lines
3. 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. Click here to see how to do this in bulk
4. Now that you know your Payer, Fee Schedule, and Timeframe review the underpayment table and identify any trends. Below are a few things to look for.
Lines with the same variance percentage
Lines with the same procedure code
Lines with the same modifier
Lines with the same provider
Lines where the providers have the same credentials
Lines during a specific timeframe
5. If nothing is jumping out at you next you will decide on which additional filter/filters you want to use. A couple of the ones I start with are listed below.
Procedure Code
Any E&M (easy to confirm as there are not a lot of additional rules/reductions that can apply)
The one with the highest number of underpaid lines
Modifier
The one with the highest number of underpaid lines
Credential for the Rendering provider
The one with the highest number of underpaid lines
%Variance
15%
Class of Contract
The one with the highest number of underpaid lines
The one that looks out of place for the fee schedule you picked
6. Review the underpayment table and identify any trends (below are common trends) adding additional filters as needed.
Lines with the same variance percentage
Lines with the same procedure code
Lines with the same modifier
Lines with the same provider
Lines where the providers have the same credentials
Lines during a specific timeframe
7. If nothing is jumping out at you still remove the filter and add a different one OR break it down further. Here is one of the ways I do this.
If you have not already added the Procedure Code filter add it now in addition to the other filter you chose.
Make sure your page is set to view 250 lines
Pick the CPT code with the highest number of underpaid lines
Now click on the Allowed Amount Column and find the most common allowed amount
Then Add the Allowed Amount filter
Change the dropdown from All to Equal and enter the most common allowed amount you found
Next, add the class of contract filter (if you have not already) and look for
The one with the highest number of underpaid lines
The one that looks out of place for the fee schedule you picked
Last, open your All Rates tool in another tab and search for the CPT/ HCPCS code (Click here to see how to use the All Rates tool)
See if the allowed amount matches the allowed amount of another fee schedule
If it does you found a false positive and need to update the fee schedule the claims are mapped to (see this article for how to do this)
8. You will do this until you have either
Verified that you found a false positive and why
add a note and change the status to invalid, send us a chat to let us know
Or you can not find that the claim lines are paid correctly and therefore have identified that the trend has correctly been identified as an underpayment.
add a note and change the status to review
9. Follow the above process until you have reviewed the entire fee schedule and are ready to move on to the next.