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Revenue and Data Reconciliation

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Resolve Discrepancies Quickly

Revenue reconciliation helps plans optimize revenue by highlighting and prioritizing discrepancies between plan data and CMS data including special statuses, demographic information, and risk scores.

The profitability of a Medicare Advantage plan depends not only on the effectiveness and efficiency of their enrollment and member management group to provide correct data to CMS, but also on the accurate recording of member premiums.

Reveleer's Revenue Reconciliation solution works directly with your enrollment solution or other core membership systems to quickly identify prospective payment and retrospective adjustment discrepancies and send them to your enrollment or member management group for resolution. Attesting to the accuracy of CMS payment reports (MMR) compared with a plan's internal records has never been simpler.

Our solution allows Health Plans to easily load membership, bid information, and MMR to quickly identify member, special status, and payment discrepancies.

Enrollment and Special Status discrepancies are captured where corrections can be made to either plan data or appeals to CMS.

Payment-level discrepancies are identified indicating issues with bid information or CMS payment processing errors.

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Features

  • Store all the CMS, plan, contract, PBP, segment, bid and business assumptions for the payment year
  • Import all key internal data sets for comparison with CMS
  • Import all key CMS reports for comparison with internal data and calculations
  • Calculate monthly prospective reimbursements and subsidies for Part A/B and D at the member, segment, PBP, contract and plan level
  • Compare internal and external results to identify discrepancies
  • Correct internal systems data or submit retro corrections to CMS via the Retroactive Processing Center (RPC) or write-off
  • Calculate year-end reconciliation amounts of prospective vs. final reimbursements and subsidies
  • Reveleer’s revenue reconciliation provides the dynamic reporting necessary to manage your revenue

Identify data and process issues early that will impact your payments from CMS by identifying and tracking member, special status and payment discrepancies between your MMR and internal data.

  • Identify payment discrepancies down to the member level
  • Revenue Discrepancy and reconciliation report library
  • Reconcile MMR discrepancies with CMS
  • Reconcile beneficiary HCC and RCC-Rx scores RAF

Set up

  • Enter CMS, plan, PBP and segment information in to Reveleer
  • Import core system data in to Reveleer
    • Enrollment
    • PDE
    • HCC
    • Rx-HCC

Calculate

  • Calculate internal forecasts
    • Member level HCC and HCC-Rx scores
    • Prospective A/B and D reimbursements and subsidies based on internal data or use CMS scores
  • Import CMS Data for comparison
    • MMR
    • CBSR
    • Plan Payment File
    • COB
    • LIS
    • Approved PDEs

Compare

  • Compare internal demographic data, member status, scores and expected prospective payments with CMS reports
  • Generate discrepancies and create work queue items in work queues
  • Resolution
    • CMS is Correct – Update internal systems of record and re-import internal data to clear discrepancy work queue items
    • Internal Systems are Correct – Create IntegriGuard documentation to submit retro adjustments to CMS systems. Pend work queue item and create expected future adjustment
    • Irresolvable – Close work queue items that cannot be resolved with reason codes to track and categorize discrepancy write-offs

Close

  • Monthly close process end the reconciliation process each month and carries forward any outstanding discrepancies to the next month
  • Reconcile
  • Calculate expected reconciliation amounts at year end based on prospective reimbursements compared to what should have been reimbursed

Reveleer’s Revenue Reconciliation module allows users the ability to view data at summary and detail levels to diagnose the reason why identified discrepancies exist and correct the problem.

                                                  

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