This morning I found an email in my inbox from the COO asking about whether we have any documentation to support how specific claims are being priced. The request is a result of a financial audit that is in process. Audits can be nerve-wracking because there is a tight timetable to respond to the auditors with the required information.
The health plan has provider contracts that price according to the Centers for Medicare and Medicaid (CMS) rules. The core claims processing system cannot price facility claims according to these rules. The health plan has a contract with a vendor that maintains an add-on software product that prices claims according to CMS rules. This software is a "black box." We have no visibility into exactly how it works. All we see is the final payment amount as the output.
I spent most of the day creating a job aid that summarizes the functionality. I was unfamiliar with the rules, so I had to scour the CMS website to find all the data elements and figure out the calculation that is used to price the claims. I did get help from some people who pointed me in the right direction. It is quite challenging to pull all the information together in a concise and straightforward document. There are a couple of people within the organization who understand this methodology, but they do not have the skillset to write a document like this one.
In fact, almost no one at the client has the chops to create documentation like this. I have a history of writing similar documentation, but the advantage of having the writing engine revved up is that I can crank these out much more quickly. I worked on it off and on and had it completed by the end of the day.
If you are curious to see the fruits of my labor, you can see the document here.
The health plan has provider contracts that price according to the Centers for Medicare and Medicaid (CMS) rules. The core claims processing system cannot price facility claims according to these rules. The health plan has a contract with a vendor that maintains an add-on software product that prices claims according to CMS rules. This software is a "black box." We have no visibility into exactly how it works. All we see is the final payment amount as the output.
I spent most of the day creating a job aid that summarizes the functionality. I was unfamiliar with the rules, so I had to scour the CMS website to find all the data elements and figure out the calculation that is used to price the claims. I did get help from some people who pointed me in the right direction. It is quite challenging to pull all the information together in a concise and straightforward document. There are a couple of people within the organization who understand this methodology, but they do not have the skillset to write a document like this one.
In fact, almost no one at the client has the chops to create documentation like this. I have a history of writing similar documentation, but the advantage of having the writing engine revved up is that I can crank these out much more quickly. I worked on it off and on and had it completed by the end of the day.
If you are curious to see the fruits of my labor, you can see the document here.
keni