Processing

Account information in Contract Manager Professional consists of the patient's billing data, which is imported at regular intervals (often daily) from the customer host system to the FinThrive system; and the reprice data, which FinThrive produces based on billing data and contract definitions.

Inevitably, some claims are not processed or are flagged, and must be reviewed by the FinThrive account representative and the customer. There are three types of reports to help you monitor claims processing.

• The Daily Process Report–a summary of claims-processing messages for a batch.
• The Exception Worklist–a user-defined report of claims-processing messages by batch or claims submission date range. The Exception Worklist is especially helpful for researching particular message codes and larger date spans.
• A/R Transaction Reconciliation–two associated reports that allow the customer to verify that all the payments and adjustments sent to FinThrive have been received and posted in the system. The reconciliation involves validating that FinThrive received all of the necessary files and that, within the files, FinThrive also received all of the individual records posted on that particular day. A/R Transaction Reconciliation includes:
  • The A/R Transaction Reconciliation Report
  • The A/R Transaction Reconciliation Detail Report

By following this process and monitoring the issues or problems that can occur, the Daily Processing Report, the Exception Worklist, and the two A/R Transaction Reconciliation reportshelp both the customer and the associated account representative to monitor the repricing process by reviewing exception messages.

The Daily Process Report and the Exception Worklist list messages to indicate the status of the data transfer. Many messages on processing reports are informational, and not strictly exceptions. Some messages refer to errors, either in the data that FinThrive imports from the host system or due to inconsistent or missing information in the system.

Files are returned with FinThrive-specific message codes indicating the status of the claim. Contract Manager can receive multiple claims for any single account. As these claims are repriced, Contract Manager charge-compilation logic considers the bill types to determine the appropriate charges. During this procedure most claims process, while others are excluded. In either situation, message codes are assigned to each claim to identify how FinThrive handled them. Message codes are also assigned at the account level to reflect an overall account status.

Message codes are listed by code and are displayed on the Exception Worklist Summary and the Exception Worklist.

• Message codes beginning with 0 apply to claims that have never been repriced.

• Message codes beginning with 10 apply to claims that have previously been repriced.

Click the message code link to view the a description of that message code.

Note: Click here to open Message Code Online Help and search for specific message codes.

Message codes are categorized into various groups. Every message code falls into at least one message group, and can be a member of more than one group. Each group can be selected to create a report specific to that message group alone.

The following table explains the various message groups.

The write-down process is an optional process that clinics sometimes adopt after contracts are fully in production. Once a clinic opts to receive adjustment files from FinThrive, they must forego manual adjustments and follow the standard write-down process described below. FinThrive can produce files for daily production, and each clinic can receive several files a day. A clinic can receive a file to correspond to each claim file submitted, or a consolidated file for that day's entire body of work (excluding corrections). In addition, FinThrive produces separate files for account override transactions and preliminary expected reimbursement (prior to discharge, if applicable).

Files can be produced in many platform-specific formats, in the FinThrive standard format, or in other custom formats, as required. FinThrive processes the adjustment file, formats it according to clinic specifications, encrypts data and places the file on the appropriate FTP site for pickup by the target clinic.

Adjustments are sent to the clinic only for successfully-repriced claims applicable to active contracts in production on or after the Cutover Date. A clinic can mark certain products not to receive adjustments. Each time a new bill in a series is sent, FinThrive recompiles the charges, reverses all previous transactions and sends a revised adjustment. Adjustments are returned to the clinic to upload to the host patient accounting system with the results of the day’s repricing, and the clinic must post the adjustments on a daily basis.

The cutover date might be different for each contract. As of the cutover date, FinThrive begins producing adjustment files for claims applicable to that contract that have an admit date on or after the Cutover Date for as long as the contract is active and in production. Claims with dates prior to the cutover date are repriced, but no adjustments are sent. The cutover date can be based on the admit, discharge, or submit date (used for government programs).

FinThrive tracks the receipt of adjustments sent to be sure that the calculated variances in actual and expected discounts remain accurate, and no manual adjustments have been posted. If an adjustment is made outside the FinThrive cycle, FinThrive stops sending further adjustments for the account in order to prevent credit balances and other accounting errors. In the FinThrive write-down process, posting manual adjustments causes “loss of control” of an account.

Note: The “control” process is an optional one and should be discussed thoroughly as part of the implementation process.

In order to achieve the greatest benefit from adjustment files, clinics must provide essential data components. In addition, return adjustment files are essentially financial transactions, whose impact on accounts receivable can be immediate and considerable. For this reason, both FinThrive and the clinic must adhere to the stringent processing requirements.

Required Data Components

• General Ledger (GL) codes
• Transaction codes

GL codes allow the transactions to be posted to the correct general ledger accounts at the clinic and, in return, allow FinThrive to post returned transactions to the correct financial category: payments, adjustments, balance transfers, etc. In the absence of patient accounting system GL codes, mutually agreed-upon mock codes can be used for the same purpose.

Processing Requirements

• Timely and Complete Posting
• Reversal Acceptance
• Updated File Acceptance

A clinic must post its files in their entirety, every day. A subsequent file corrects any errors with recalculations. This protects the integrity of the transactions and ensures that the system balances. Failure to post a file can cause serious repercussions.

FinThrive must be able to send reversals in the event of a recalculation. Recalculations can be caused by retroactive rate changes, amendments, or rebills.

A clinic must be able to accept update files or files that are not tied to a specific day's claims. These are used for corrections or updates and can span several days or months of claims input. If a clinic makes manual corrections on accounts, those accounts are not eligible to receive system-generated adjustments again.