Calculate Reimbursement

Use the Reprice Comparison page to calculate the expected reimbursement for an account, using the secondary payor profile terms and Coordination of Benefit (COB) language.

The Reprice Comparison page calculates the expected reimbursement using a selected secondary payor as the primary, and displays the new calculated reimbursement next to the original reimbursement.
Using the billed charges, primary reimbursement, and secondary reimbursement, it then calculates the expected COB payment for the most common types of COB language that might be included in your contract.
This information can help you assess the collection effort to obtain additional payment owed by the secondary payor under that payor’s COB provision.

Field Descriptions

The following table describes each of the fields on the Reprice Comparison page. The fields are listed in alphabetical order by section.

Field	Description
Patient Summary
Account Number	Patient account number (for UB claims) or insured ID (for CMS-1500 claims)
Patient Name	Patient name
Master Account Summary
EOB Discount	The discount amount from the Remittance Advice (Explanation of Benefits).
Master Account Balance	Billed Charges, minus total payments, minus total adjustments at the master account level
Miscellaneous	Sum of all non-billable amounts for all accounts associated with this account number
Non-Contractual/ Other Adjustments	Other, non-insurance adjustments
Patient Payment	Sum of the payments made by the patient for all accounts associated with this account number
Payment Variance	Sum of the payment variance for all accounts associated with this account number, calculated as Total Expected Reimbursement minus the actual payment. If Patient Liability does not exist, it is calculated as Expected Payment - (Total Insurance Payment + Total Patient Payment). If Patient Liability exists, it is calculated as Expected Payment - (Insurance Payment + Total Patient Liability).
Total Cost	The total cost amount associated with this account. Negative values display in red with parentheses. The Total Cost value only displays if your facility has a cost accounting system that sends Contract Manager cost on either a CDM or case level, and the cost and profitability feature has been activated for your facility. For more information, refer to Cost and Profitability Information.
Total Detail Charges	Total of all detail charges for all accounts associated with this account number
Payor Summary
Current Reprice	The type and date of the reprice currently displayed. This field displays if there is only one reprice for the account.
Payor Name	Name of the payor
Reprice Summary
Actual Discount (Insurance)	Total insurance adjustments for all accounts; Explanation of Benefits (EOB) write-off
Admit Date	Date of admission for the account
Bill Type	Bill type
Billed Charges	The total charges incurred for the claim or set of claims that have been repriced
Dates of Service	The range of date of service from and date of service to for the claim
Discount Variance	Expected Discount minus the Actual Discount.
Expected Discount	Billed Charges minus Non-covered Charges, minus Total Expected Reimbursement
Expected Insurance Payment	The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data, minus patient liability
Insurance Payment	The amount paid by the insurance company
Insurance Payment Write-offs	The total adjustments paid by the insurance company
Medicare Outlier Date	The date on which Medicare Inpatient claims reach the outlier threshold, based on detail charges
Non-Covered Charges	The amount of non-covered charges (not disallowed charges)
Other Contractual Write-offs	Other insurance adjustments not included in the discount variance
Patient Liability	The amount the patient is responsible for
Patient Type	Patient type assigned to the account: Inpatient/Outpatient
Primary Diagnosis	Primary diagnosis code. This field provides a link to additional information about the code. Click the link to view basic information about the code. KnowledgeSource subscribers can log in to KnowledgeSource to view detailed information about the code.
Product/Plan ID	Name or plan ID of the insurance product
Total Contractual Write-offs	Total of all adjustments
Total Expected Payment	The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data
Selection Criteria
Contract Profile	Compares results between contract profiles. Select the contract profile to compare reprice results against.
Display Coordination of Benefits Comparison	Displays the COB reimbursement amounts for the standard types of COB language.
Product	Compares results between insurance products. Select the product you want to compare reprice results against.