Payment Mismatch Tracking

1. Display the Payment Mismatch Tracking page: On the Main Menu, click Reports. Under FINANCIALS, click Payment Mismatch Tracking.
2. Start/end date — Enter or select the date range for the report. You can enter dates in the "from" and "to" fields, or you can select a time frame from the menu.
   Note: If you run this report for a time period longer than 30 days, use filter fields to limit the report results. For example, if you run the report for a 1‑year time frame, set filters to focus on a single payer or IRC (insurance reporting category) and then filter on other items, such as procedure codes, insurance package IDs, etc.
3. By date of — Select Service to report on payment mismatches by date of service. Select Payment Post to report on payment mismatches by date of payment post.
4. Allowable schedules — Select a schedule from the menu. You can select only one allowable schedule when you run the Payment Mismatch Tracking report.
   Note: Make sure that any other filter selections are part of the selected allowable schedule. For example, if you select a value for Product type, the product type must be included in the selected allowable schedule.
5. Procedure code(s) —
• To report on a set of procedure codes, enter the procedure codes in the fields. (Additional fields for procedure codes appear after you use the first eight fields.) You can type a period to access the Procedure Code Lookup tool. You can also use wildcards (for example, 992*) to include a set of similar procedure codes in the report, and you can enter ranges, for example, 99000-99100.
• To report on all procedure codes, select the Show All Procedure Codes option.
• To report on mismatched payments regardless of procedure code, leave the fields blank.

Note: Charges associated with procedure codes that are not included in an allowable schedule appear in the # unknown and $ payments for unknown charges columns in the report results.

6. Excluded procedure code(s) — Enter procedure codes that you want to exclude from the report results. Charges with excluded procedure codes will not appear in the report results.
   You can type a period to access the Procedure Code Lookup tool. You can also use wildcards (for example, 992*) to exclude a set of similar procedure codes in the report, and you can enter ranges, for example, 99000-99100.
7. Modifier(s) —
• To report on mismatched payments for specific procedure code modifiers, click show selected and then select one or more modifiers from the list.
  Note: An asterisk next to a modifier in the list indicates a fee-affecting modifier.
  
• To report on practice-wide mismatched payments summarized by procedure code modifier, click show selected and then select Show All.
• To report on procedure code modifiers that affect reimbursements, click show selected and then select Show All Reimbursement Impacting.
  
8. Procedure fee — Enter a dollar range in the minimum and maximum fields to report on mismatched payments where the charge value of the procedure code is within that dollar range only (the range is inclusive).
   Note: Leave the maximum field blank to report on all amounts greater than the minimum value.
9. Medical groups —
• To report on mismatched payments for specific medical groups only, click show selected and then select one or more medical groups from the list.
• To report on practice-wide mismatched payments summarized by medical group, click show selected and then select Show All.
10. Provider groups —
• To report on mismatched payments for specific provider groups only, click show selected and then select one or more provider groups from the list.
• To report on practice-wide mismatched payments summarized by provider group, click show selected and then select Show All.
11. Provider —
• To report on mismatched payments for specific providers only, click show selected and then select one or more provider usernames from the list.
• To report on practice-wide mismatched payments summarized by provider, click show selected and then select Show All.
12. Service department —
• To report on mismatched payments for specific service departments only, click show selected and then select one or more service departments from the list.
• To report on practice-wide mismatched payments summarized by service department, click show selected and then select Show All.
13. Insurance reporting category —
• To report on mismatched payments for specific insurance reporting categories only, click show selected and then select one or more insurance reporting categories from the list.
• To report on practice-wide mismatched payments summarized by insurance reporting category, click show selected and then select Show All.
14. Global allowable category — An allowable category represents a group of payers that use the same allowable schedule.
• To report on mismatched payments for specific global allowable categories only, click show selected and then select one or more global allowable categories from the list.
• To report on practice-wide mismatched payments summarized for each global allowable category, click show selected and then select Show All.
15. Local allowable category (practice created) — Local allowable categories are created by combining any of the following insurance package attributes: insurance reporting category, product type, and insurance package. Local allowable categories are then linked to a practice-defined allowable schedule. (See the Local Allowable Categories page.)
• To report on mismatched payments for specific local allowable categories only, click show selected and then select one or more local allowable categories from the list.
• To report on practice-wide mismatched payments summarized for each local allowable category, click show selected and then select Show All.
16. Product type — Product types include HMO, POS, PPO, Medicare HMO, etc.
• To report on mismatched payments for specific insurance product types only, click show selected and then select one or more product types from the list.
• To report on practice-wide mismatched payments summarized for each insurance product type, click show selected and then select Show All.
17. Insurance package IDs —
• To report on a set of insurance packages, enter the insurance package IDs in the fields. (Additional fields for package IDs appear after you use the first eight fields.)
  Note: You can type a period to access the Insurance Search Lookup tool.
• To report on mismatched payments for all insurance packages, select the Show All Insurance Packages option.
• To report on mismatched payments regardless of insurance package ID, leave the fields blank.
  
18. Unknown allowable amounts — Select an option to include or exclude unknown allowable amounts in the report. Including unknown allowable amounts allows you to see charges where an estimated payment amount cannot be determined because an allowable schedule does not exist.
• Show All Charges — Include all paid charges, including unknown allowable amounts, in the report (the default option).
• Only Show Charges With Known Allowable Amounts — Exclude unknown allowable amounts from the report.
• Only Show Charges With Unknown Allowable Amounts — Include only unknown allowable amounts in the report.
19. Report format — Select an option.
• XML — Display the report results on your screen. You can sort, resort, and drill down in the Web browser.
• Comma-Delimited Text — Download the report results to Excel.
20. Click Run Report.
    The report results appear at the bottom of the page or are downloaded to an Excel file.

1. Display the Payment Mismatch Tracking page: On the Main Menu, click Reports. Under FINANCIALS, click Payment Mismatch Tracking.
2. Run the report as described in "To run a payment mismatch tracking report."
3. Click a linked number under the # below exp. allowed amt. column or the # above exp. allowed amt. column. The list of charges appears in the Task Bar. The worklist includes the following information:

• Patient name and ID
• Payer
• Claim ID (clm)
• Procedure code (code)
• Actual payment (allowed amt.)
• Expected payment (exp. allowed amt.)

You can click the claim ID to display the Claim Edit page. To return to the Payment Mismatch Tracking page from the Claim Edit page, click Return to report at the top of the payment mismatch worklist.

To download the contents of the payment mismatch worklist, click Download as CSV at the top of the worklist.

If values appear in the # out-of-date column in the report, you may see a message about repricing these out-of-date charges. The message displayed depends on whether you have more or fewer than 10,000 charges in the # out-of-date column.

1. Display the Payment Mismatch Tracking page: On the Main Menu, click Reports. Under FINANCIALS, click Payment Mismatch Tracking.
2. Run the report as described in "To run a payment mismatch tracking report."
• If there are fewer than 10,000 charges in the # out-of-date column, this message appears: "There are N charges that may be out-of-date. To reprice out-of-date charges, click here."
• If there are more than 10,000 charges in the # out-of-date column, this message appears: "You have selected more than the reprice limit of 10,000 charges. If you reprice these charges, only the first 10,000 will be repriced. You may repeat this action as many times as necessary to reprice more charges. Please note that if you don't need to reprice charges immediately, athenaOne automatically reprices out-of-date charges each evening. The nightly repricing has a limit of 1,000,000 charges, so if you have a very large number of charges, it may take more than one evening. Reprice out-of-date charges."

Note: The nightly repricer recalculates the estimated allowed amounts for charges with dates of service up to 104 weeks (2 years) ago from today. If older claims have recent transactions, they are not recalculated by the nightly repricer, but they can be manually recalculated in batches of up to 10,000 charges.

3. If you have fewer than 10,000 charges, click click here to reprice your charges. The Elapsed Time Counter appears while athenaOne recalculates estimated allowed amounts for your charges. Your repriced charges appear on the Payment Mismatch Tracking page.

To provide the information payers need to resolve payment issues, you can download Payment Mismatch Tracking report results to a .csv file. In Excel, you can rearrange columns and format the data to meet the payer's requirements — much faster and easier than printing out and faxing the EOB for each claim!

1. Display the Payment Mismatch Tracking page: On the Main Menu, click Reports. Under FINANCIALS, click Payment Mismatch Tracking.
2. Run the report as described in "To run a payment mismatch tracking report."
3. In the report results at the bottom of the page, click a linked number to display the claim information in the Task Bar.
4. In the Task Bar, click Download as CSV.
   The CSV file is generated and appears at the bottom of the Task Bar.
   
5. Click the file name to open the file in Excel.
   The charge information appears in these columns in the spreadsheet:
   • ID — The charge ID from the report you downloaded, so you can discuss individual charges with the payer.
   • CLAIMID — The ID of the claim that includes the charge.
   • FROMDATE — The From date on the Claim Edit page (typically the date of service).
   • DEPARTMENT — The Service Department you selected when you ran the Payment Mismatch Tracking report.
   • PROVIDER — The provider's username.
   • PROCEDURECODE — The procedure code on the charge.
   • MODIFIER — The modifier on the charge.
   • UNITS — The number of units on the charge.
   • CHARGE AMT — The amount of the charge.
   • EXP ALLOWED AMT — The allowed amount for the charge, according to the allowable schedule. This is the amount we expect the payer to allow for this charge. The payer may pay a portion of this expected allowed amount, with the remainder covered by the patient's copay or deductible.
   • ALLOWED AMT — The amount the payer actually allowed for the charge.
   • PATIENTID — The athenaOne patient ID.
   • PATIENTNAME — The patient's name.
   • DOB — The patient's date of birth.
   • ID/CERT# — The payer's patient ID, from the ID/CERT# field on the patient Quickview.
   • INSURANCEPACKAGE — The insurance package number on the claim.
   • POLICYNUMBER — The payer's policy number; this number is also shown in the Group# field on the patient Quickview and in the Policy/group number field on the Update Policy Details page.
   • CASENUMBER — The payer-assigned case number; this number is also shown in the Worker's Comp claim number field on the Update Worker's Comp Policy Details page and on the patient Quickview.
   • PRODUCTTYPE — The insurance package's product type.
   • SCHEDULEID — The ID of the allowable schedule that priced the charge.
   • SCHEDULEID — The name of the allowable schedule that priced the charge.

The Payment Mismatch Tracking report uses your practice's allowable schedules to list payments received on primary insurance charges that were outside the expected range, according to your practice's allowable schedule. 

Note: The Payment Mismatch Tracking report uses the number of units billed when calculating the total value of the expected payment.

athenahealth recommends defining allowable information for the top 15 procedure codes for the top four payers. To properly configure this information, you should contact the CSC by selecting Support > Create Case or Call in the Main Menu.

Note: The thresholds for minimum and maximum allowables are set in the allowable schedule associated with the charge. Charges associated with procedure codes that are not included in an allowable schedule appear in the # unknown and $ payments for unknown charges columns in the report results.

athenahealth recommends that you run the Payment Mismatch Tracking report monthly or quarterly (by procedure and IRC or by allowable category) to highlight potential issues. Sort the report by volume to see which procedures and payers are most problematic.

• Note the number of times that the procedure was paid correctly and compare this number to the number of mismatches; if all the charges are paid incorrectly, there may be an underlying error in contract implementation in the payer's system.
• If the schedule is not based on the Medicare algorithm and many charges are paid incorrectly, check to see whether a modifier or multiple charges are present on the claims with suspected mismatches (claims with single charges are likely to return the most accurate results).
  Note: You may want to run the report at the insurance package level to reveal a pattern that could explain the inconsistency.
  
• Try to pinpoint the beginning of the problem: run the report with a start date further in the past to identify the start date of the problem.

Patterns of payment that suggest fundamental contracting issues are best handled in bulk, by contacting the payer's provider relations or contract representative, rather than on a claim-by-claim basis through the usual claim adjudication and appeal process. If the payer agrees with the underlying assessment, a lump sum adjustment may be the method of recourse, rather than a claim-level reprocessing. As such, claim processors are not the appropriate decision-makers to engage.

Your practice should find the following report columns extremely helpful when it comes time to review a payer's performance:

• # at exp. allowed amt. — The number of claims paid at the rate or allowed amount stored in the allowable schedule.
• $ at exp. allowed amt. — The total dollars allowed at the contracted rate, per the payer's allowable schedule for this charge scenario.

In advance of a contract renewal meeting, your practice should review how many of the payer's claims were paid at the contracted rate compared to claims paid under the contracted rate. Your practice should also review the percentage of claims routinely underpaid by the payer with their provider relations representative.