User Guide — Payment Yield

 

When a claim appears to have been paid below or above the expected allowed amount, you can review the claim and see that it was priced by an unexpected allowable schedule.

 

For example, if you determine that the HMO allowable schedule should have priced the charge, instead of the PPO allowable schedule, you can easily change the product type, so that the proper allowable schedule is pricing the claim.

 

To correct the policy's Pricing product type:

1. Display the patient Quickview: In the text box at the top right of the Main Menu, enter the first three letters of the patient's last name, followed by a comma, followed by the first three letters of the patient's first name. Click the search icon. On the Find a Patient page, click Quickview for the patient you need.
2. In the Insurances section, click Update this policy for the relevant insurance policy. The Update Policy Details page appears.
3. On the Update Policy Details page, select the correct product type from the Pricing product type list.
4. Click Update Policy.

To see the result of changing the Pricing product type, you have three options:

• Open the Claim Edit page for the claim that you are researching and click Save Claim. On the Claim Review page, click edit claim to return to the Claim Edit page. This operation reprices the charge according to the allowable schedule for the pricing product type you selected.
• If the claim is in the reporting range you select on the Payment Mismatch Tracking report, athenaOne prompts you to reprice it, along with the other out-of-date claims in the Payment Mismatch Tracking report results.
• Wait for athenaOne to automatically reprice the claim overnight.

Note:

• This change updates only this specific patient's Pricing product type; this change does not update the insurance package itself.
• If the patient has several claims, this change applies to all claims created under this policy.
• The policy dates are still in effect, so the Pricing product type does not apply to any of the patient's prior policies.

 

Some claims display -Unknown- in the Expected Allowed Amount field. Follow these steps to see why athenaOne isn't pricing the charge:

1. Click the magnifying glass icon next to -Unknown-.
2. A pop-up box appears and asks you to select the allowable schedule from the list that you believe should have priced the charge.
3. Select the allowable schedule and click Go.
   athenaOne displays the reasons why the charge appears as -Unknown-. The reasons vary, depending on the circumstances of the particular charge. More than one explanation may apply to a given charge.

 

The key components of our Payment Yield functionality are:

• The Allowable Schedule Worksheet — Use this page to help you gather all the information you'll need to enter an allowable schedule, along with its terms and conditions, into athenaOne so that you can take advantage of the athenaOne enhanced allowable amount estimation capabilities.
• The Allowable Schedules page — This page provides fields and links that give you information about the notice period for your payer contract, an allowable schedule audit history, access to the Allowable Schedule Terms and Conditions page, and the ability to set the display order of your allowable schedules.
• The Allowable Schedule Terms and Conditions page — On this page, you can enter multiple conditions, reimbursement methods, and adjustments for each allowable schedule. This degree of specificity drives the ability of athenaOne to accurately estimate the allowed amounts for your charges.
• The Claim Edit page — With fields and a icon, you can click to view the details of the allowable schedule and the terms and conditions that athenaOne used to calculate the estimated allowed amount for the charge.
• The Payment Mismatch Tracking page — Includes the recalculation of estimated allowed amounts, so that you can immediately see the impact of changes to your allowable schedule, or associated terms and conditions, without having to wait for athenaOne to automatically update pricing of your charges overnight.

 

When the Include net A/R option is selected, the A/R Aging Wizard report results include two sets of columns:

• The GROSS columns show the sum of charge amounts (including transfers and payments) outstanding for each date range.
• The NET columns show the sum of the expected allowed amounts for those charges, less any payments or transfers.

Because the copayment is not subtracted, the NET TOTAL amount can be larger than the GROSS TOTAL amount. This discrepancy can also occur when a payer overpays a given charge. For example, if the expected allowed amount for a charge is $400, but the payer accidentally makes two payments of $400, the NET TOTAL column displays $400, but the GROSS TOTAL column displays -$400, a difference of $800.

 

If there is no expected allowed amount for a charge, athenaOne uses the full charge amount.

 

The Activity Wizard report results also include:

• current exp allowed amt — The expected allowed amount for the charges in the current chg column.
• late exp allowed amt — The expected allowed amount for the charges in the late chg column.

You can also use Report Builder to create payment yield reports showing transaction activity and transaction aging:

1. Display Report Builder: On the Main Menu, click Reports. Under General, click Report Builder.
2. Type column — Click the Transaction Activity option, then click Next.
3. On the Choose Display Columns tab, open the Measures section to use these display columns:
   • Sum of Actual Allowed Amounts ($)
   • Sum of Expected Allowed Amounts ($)
   • Sum of Allowable Difference ($)

4. Type column — Click the Transaction Aging option, then click Next. On the Choose Display Columns tab, open the Measures section to use these display columns:

   • Aging of Actual Allowed Amount By Date of Service Buckets ($)

   • Aging of Expected Allowable Amount By Date of Service Buckets ($)

   • Aging of Difference between Actual and Expected Allowable Amount By Date of Service Buckets ($)