Understanding Fee Schedules | Rivet Help Center

Rivets loads and builds out the uniquely contracted rates for your fee schedules so we can create accurate patient cost estimates and accurately price claims.

Viewing fee schedules
Fee Schedule Rules
Fee Schedule Adjustment Rules

1. Viewing fee schedules

To navigate to the fee schedule page, select Payer in the upper left-hand corner, and then click Fee Schedules. This will direct you to the fee schedule table.

The Fee Schedule Table shows all the fee schedules in the account. Several actions can be taken from the table including Edit, Clone, and Delete.

On the table, you will see the labels for each column of information. You might have to scroll to the right to see all of them.

A couple of things to note are:

Start>The effective date of your fee schedule
Last Modified>The last time someone from your office or Rivet made a change to that schedule
Last Revision> The most recent version date,

Filters:

There are filters in the Fee Schedule Builder that allow you to see your information in more customizable ways to your workflow.

The Current filter allows you to switch between your fee schedules that are Active, Inactive, or both (All).

The Rate Type filter allows you to show rates according to the type of location that the fee schedule applies to, whether that be Professional, Non-Facility, or ASC.

You can choose any combination of rate types to show.

The Business Unit filter separates each fee schedule into the Business Unit (TAX IDs) that they were made for.

You can select multiple at a time, or all of them to compare across Business Units.

The Payer Filter sorts the fee schedules by what payer they were built for.

You can select multiple or all of the payers in the dropdown menu.

The Payer Filter sorts the fee schedules by what payer they were built for.

You can select multiple or all of the payers in the dropdown menu.

2. Fee Schedule Rules

Sometimes fee schedules need to be adjusted or updated this is a simple process with the fee schedule rule builder. To edit a fee schedule go to payer > fee schedule > select a fee schedule > rules tab.

In the rules tab you can add new rules or adjust existing rules in a variety of ways. Each rule will need two pieces configured to calculate rates for a code. Rules apply top to bottom so if you have several rules that apply to the same code the top will apply first. A rate calculation can be set to apply to ANY or ALL of the rules for a particular set of codes so you can have multiple rules configured to be more specific or to be more broad and have multiple ways the rule can be applied.

Pay with: How to calculate the rate

CMS baseline %: Percentage of the standard CMS fee schedule rules loaded
CMS conversion factor: Load a conversion factor from cms that can be adjusted
Fixed Amount: A set amount for a particular code or set of codes
Percent of charge: with Estimates a percentage of the chargemaster uploaded to the account or percent of the charge rate on a claim
Custom baseline: A file that has been provided from the customer typically a spreadsheet of rates that is uploaded to Rivet
Per diem: A form of payment for services in which the provider is paid a daily fee for specific services or outcomes, regardless of the cost of provision. Per diem rates are paid without regard to actual charges and may vary by level of care, such as medical, surgical, intensive care, skilled care, psychiatric, etc. Per diem rates are usually flat all inclusive rates.
Per visit: A per-visit hospital reimbursement structure is a payment system in which hospitals are paid a fixed amount for each patient visit, regardless of the services that are provided. This type of reimbursement structure is often used for outpatient visits, such as doctor's appointments and diagnostic tests.
Case rate: Flat rate, applied to whole claim, ignoring units.

Apply to: What part of the fee schedule the rule applies to.

Code: A list of codes that can be bulk-selected

Additional criteria can be configured:

Is any of
Is none of

Code input: manually enter a code value
- Is equal to
- Contains
- Does not contain
- Starts with
- Is empty
- Is not empty
- Is between
Facility type: choose what facility type this rule applies to
- Is
- Is not
- contains
Modifier: typically an additional rule included with code or code input to adjust and apply the calculation only if a modifier is added with the code.
- Is equal to
- Contains
- Does not contain
- Starts with
- Is empty
- Is not empty
- Is between
Revenue code: Defines where services within hospital is being rendered
- Contains
- Is none of
- Is empty

Once the rules are configured for a fee schedule there are a variety of additional adjustments that can be made that apply separately from these rules these can be found by clicking on the adjustments tab in a fee schedule.

3. Fee schedule Adjustments

Adjustments are used to configure specific adjustments for fee schedules such as provider type modifiers and multiple procedure payment reduction. Rivet loads a default configuration for each payer with a standard system rule set but adjustments can be made further to match the details in the contract.

Adjustments can be found by navigating to the adjustments tab on a fee schedule. We will have it broken down into several sections that can be configured for that fee schedule. Adjustments apply to all fee schedule versions.

System Rule Set: A preconfigured set of rules by payer and contract type like Humana Commercial or Humana Medicare Advantage.

Rules: A variety of different rules that can be configured for a fee schedule

Incentive pay adjustment
Sequestration
Rank multiple procedure reduction by allowable or RVU
AS, 80, 81, 82, SA modifiers use allowable or fee schedule rate
Fee Schedule effective date lag time
Exclude codes from provider-type discounts
Bill incident: specifies whether Rivet should calculate the expected allowable based on the rendering or supervising provider
Wage Index
How to apply a lesser of clause
Use admission date or discharge date

Modifiers: Percentage adjustments for code modifiers

General

Modifier 50: Adjust percentage
Modifier 22: Adjust percentage
Modifier 25: Adjust percentage
Modifier 52: Adjust percentage
Modifier 53: Adjust percentage
Modifier 62: Adjust percentage
Modifier 66: Adjust percentage
Modifier 73: Adjust percentage
Modifier 74: Adjust percentage
Modifier FY: Adjust percentage

Split Care

Mirror CMS: rates for Split care modifiers or specify modifier reductions

Modifier 54: Adjust percentage reduction
Modifier 55: Adjust percentage reduction
Modifier 56: Adjust percentage reduction
Modifier 78: Adjust percentage reduction

Anesthesia

Modifier QX: Adjust percentage reduction
Modifier AD: Adjust percentage reduction
Modifier QK: Adjust percentage reduction
Modifier QY: Adjust percentage reduction
Modifier QZ: Adjust percentage reduction
Minutes per unit: How Many Minutes are one Anesthesia Unit
Rounding: When minutes convert to fractional units, how should rounding work? Input the nearest unit (tenth = 0.1) and whether to round up at 5 (standard) or round up always
Modifier P3: Risk modifier units — used to indicate physical status during the anesthesia procedure. How many additional units should be added to base
Modifier P4: Risk modifier units — used to indicate physical status during the anesthesia procedure. How many additional units should be added to base
Modifier P5: Risk modifier units — used to indicate physical status during the anesthesia procedure. How many additional units should be added to base