A contract profile is an electronic version of a paper contract that contains terms and conditions. The system uses the contract profile and claims to calculate expected reimbursement.
The Terms and Conditions (TAC) portion of the contract profile contains all of the service types and reimbursement terms that, in turn, contain the definitions and formulas used to calculate expected reimbursement in Contract Manager.
Service Types
A service type describes a particular service provided by your facility, such as CT Scan. The definitions for that service type identify the codes associated with that service. The service type definition is what allows a claim to match to a contract to calculate the reimbursement amount.
The service type definitions are stored in service type tables that can then be associated to a contract profile so that the service types in the table are available for that profile and can be added to the Terms and Conditions for the profile through the Consolidated Profile Editor page.
There are three types of tables where the service types can be stored:
- Universal – Includes the most common service types and is automatically associated with all profiles. Universal service type tables are created and maintained by FinThrive only.
- Facility Level – Includes service types that are common for your facility and is available for association with all profiles created in a specific facility. Facility level service type tables are created and maintained by FinThrive only. For multi-level facilities, FinThrive can also create a regional table at the CBO or RBO level.
- Contract Level – Includes service types that are unique to a specific contract. Once created, you must associate this table with the profile.
Note: For this release, the Consolidated Profile Editor page only supports Universal service types.
Terms and Conditions
The Terms and Conditions portion of the contract profile is divided into the following sections:
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Exclusions |
The Exclusions section contains services and products that are excluded from percentage reimbursement. During recalculation, if the system finds a matching service type in this section, it subtracts the expected amount from billed charges to produce billed charges adjusted. Therefore, billed charges adjusted is equal to billed charges minus the expected amount of any service loaded in the Exclusions section. |
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Pass-Through |
The Pass-Through section typically contains services and products for which cost is passed through to the payor (for example, specialty items such as implants and high-cost drugs). Calculations from this section are added to those in the Reimbursement section. |
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Reimbursement |
The Reimbursement section contains services and products for which the negotiated rates are calculated. The majority of a contract’s definitions and formulas are contained in the this section. During recalculation, if the system finds a matching service type in this section, it pays the rate calculation. |
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Stop Loss/Cap |
This section contains definitions of stop loss and stop cap clauses. These are the terms that provide for the protection of the provider or payor from high dollar claims. If “lesser-of” or similar clauses are present in the contract, they are entered in this section. The calculations in this section override all calculations from other sections when a stop loss/cap clause is applicable in a contract. |
Ranking
Claims often qualify for multiple service types. When reimbursement for a claim is calculated, the system references each TAC section and each service type within that section in the order in which they appear on the Consolidated Profile Editor page. For example, the reimbursement calculation moves through each TAC section as follows:
- Exclusions – Subtracts the expected amount for the service type from billed charges.
- Pass-Through – Adds the expected amount for the service type to the amounts in the Reimbursement section.
- Reimbursement – Pays the rate calculation calculated by the specified reimbursement method.
- Stop Loss/Cap – Overrides all calculations from previous sections with the expected amount for the service type.
Each service type definition includes a default rank that orders where it appear on the Consolidated Profile Editor page. A lower number indicates a higher rank. For example, when a claim qualifies for two service type definitions — one ranked 10 and the other ranked 100 — the service type ranked 10 is reimbursed before the one ranked 100. However, you can override this default ranking for each profile. To change the rank order of any service type, you can simply drag and drop the service type to the desired location in the list of service types.
- The position of the service type on the View Contract Profile page determines its rank. The reimbursement calculation moves through the service types in sequential order from the top of the page to the bottom. Each service type has a higher priority than the service type below it. You cannot change service type ranking if any service type in the profile is in the edit mode.
- The CPE page displays the original rank and the override rank for each service type. The original rank does NOT display when you are in the edit mode.
Note: You cannot drag a service type from one TAC section to another. You can only change its rank order within the current section. For example, you cannot drag and drop a service type from the Pass-Through section to the Reimbursement section.
Rank Guidelines
FinThrive uses the following guidelines to determine rank:
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Universal |
Use the Universal service type table as a starting point to rank other service types |
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Type of reimbursement |
Case-based reimbursement ranks higher than line-item reimbursement |
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Amount of reimbursement |
Generally, service types with higher reimbursement rank higher |
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Patient type |
Inpatient and outpatient service types may have the same rank, since a claim only qualifies for one or the other |
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Default |
The following default service types rank lower than all other service types:
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Specificity |
More specific service types rank higher |