Fee Analysis Report Instructions
The task of analyzing reimbursement by MCOs is critical to the profitability of your business. You need to know which HCPCS codes and MCOs reflect the majority of your revenues. The MedFlex® Fee Analysis Report takes advantage of the 80/20 rule - 80 % of your revenues are generated from 20 % of total HCPCS codes.
Once the data for is compiled, the report presents a summary of the information showing how many pages down (procedures) and how many pages across (payers) the report would be if all data were selected. The choice of how many pages down and across you should select can be answered by pressing F7 & F8 function keys. These function keys review for you what percentage of your business is on what page count. More than likely 80% of the business will cover less than five pages down and across equaling a total of 25 pages. As shown on the screen the entire report can be thousands of pages long. By narrowing what you are reviewing to the cpt/payers that affect the main 80% or your business we increase the effectiveness with which we can audit contract compliance. This 80% view also lets us focus on what are the normal real life reimbursements we are getting for our main codes/payers so we can make informed contracting decisions.
The fee analysis includes the following:
What procedures and carriers are driving the business?
Real reimbursement amounts as opposed to usual and customary price levels. Usual and customary has come to mean that inflated price with which to use as the basis to create the impression of a large discount when quoting contracts. To negotiate real contracts nowadays one must know real information to know what monies are really being received for procedures across a wide range of payer types.
The average reimbursement amount for each procedure.
The lowest and the highest dollar amount received on each procedure by any payor.
The lowest and the highest paid by each payor.
In reality, this report will determine which insurance carriers pay acceptable fees and which ones do not. This information will allow you negotiate with MCOs to maximize your reimbursement and profitability.
RANK CPT COUNT
LOW AVG HIGH
1 L1960 263
196.93 462.11 605.00
8.2% of Sales 8.2% Cumulative
Rank - The rating for each procedure code.
CPT - The procedure code.
Count - The number of times this procedure code was billed in the time period chosen.
Low - The lowest dollar amount received by any one payor.
Avg. - The average dollar amount received by all payors.
High - The highest dollar amount received by any payor.
% Of Sales - Not the percentage of gross sales, but the percentage of closed invoices for the time period chosen.
% Of Cumulative - The percent of sales added together in ascending order.
Ranking 1 2
Payor Code PATIEN 586
Payor Name PATIENT PAY DMEPOS NON-ASSIGN
Total Paid 330,308.56 243,157.32
% of Total 22.2 16.4
Cumulative % 22.2 38.6
Ranking - Ranked by cash receipts received for the closed invoices in the time period chosen.
Total Paid - The total of cash received for each payor for the time period chosen.
% Of Total - The percent of the total cash receipts that reflects the percent of the business.
Cumulative % - A running total of the percents in ascending order.
Count - The total amount of times this procedure code was billed to each payor.
Contract - The contract amount with each payor. If 0, this means the contract reimbursement amount has not been defined in the system.
Dis* - The number of procedures that were written off and no money was collected from that primary carrier.
Low - The lowest dollar amount this payor paid excluding disallowed billing. If disallowed billing were included then the low would show 0 instead of the lowest reimbursement actually received from that carrier. The purpose of the low - average - high line is to highlight those payers that are varying their reimbursements and disallowing procedures. If you have a contracted reimbursement amount that was agreed to by both parties then the reimbursement amount should not be varying. By using the companion cpt/payor zoom report, you can audit a particular cpt/payor combination to provide you the information you need to confront the payor and get the full contracted reimbursement.
Avg. - The average of all payments for this payor. Keep in mind that if this number is less than the low number, then this carrier disallowed some claims. Refer to the numbers in the upper left and right corners of the box. If the number in the right corner is anything other than a zero, this number represents the number of claims that were not paid.
High - The highest dollar amount this payor paid.
The low, avg. and high amounts do not include the 2nd(3rd…) insurance or the amount the patient paid.
Medicare - Medicare's allowable amount. The Medicare amount has become the benchmark figure that most contracts are negotiated against. We show this figure so you can determine how a given payer/cpt combination is performing in comparison to the Medicare reimbursement.
Total Paid - The total paid (all parties) for an individual carrier including secondary payors and patient payments.
Medi% - Given the total amount paid by all parties, this field calculates the percentage over or under the Medicare allowable. This field lets you know what procedure codes to raise the prices on with each carrier or whether or not to accept assignment.