Government exchanges and healthcare payors: How data mismatch still complicates a full solution for billing reconciliation

Annette Schoellman
Consulting Senior Practice Director

For healthcare payors participating in exchanges, reconciling amounts they have billed to the Centers for Medicare and Medicaid Services (CMS) for covered consumers against payment subsidies received has long been a monumental task. Over the years, many have attempted to resolve this. But solutions are evading payors due to two significant issues: data mismatches and the timing of enrollments vs. payments. The combination of the two often results in a tangle wherein it becomes difficult to prove what is owed in the time period allowed, with payors eventually writing off large amounts of unresolved accounts receivable (AR).

The major problem: data mismatches between payor and CMS enrollment records

Data mismatches are the most common problem with reconciling payors’ records to those of CMS. These include all of the common data issues experienced during any migration, such as a middle initial on one side’s enrollment record but not on the other or a name like Mary Ann combined to MaryAnn. When payors submit their files to CMS, it expects the data to be in the format that it has on record; otherwise, those records fallout as a non-covered member, and payment is not sent. However, for payors to reconcile the payment when it comes to their side, the data must be in their records format. Thus, it begins an endless cycle of trying to fix records, submit updates, and hoping that CMS will accept the reconciliation and release the payment. 

The secondary problem: timing of disputes versus billing and payments

Timing is the second issue exacerbating the cycle. It takes time for a payor to work through all of the fallout records initially submitted, find the issues, send corrections proving that payment is warranted, etc. Once those corrections are submitted to CMS, it can easily take 30 days to work through the file on their side. When this is completed on both sides, another month or two of billing and payments has likely passed. Those same records that failed in prior months will show up on the fallout report repeatedly, meaning that the same errors are being reworked over and over.

A possible solution for healthcare payors

Most payors are attempting to deal with this issue through a mixture of solutions: software that can solve part of the reconciliation, experienced teams that work the errors, etc. A full solution does not exist so far. The ideal solution should tie member records in both formats together – the one submitted by members to the payor and the one held by CMS – and translate outgoing billing records and incoming payment records between the two. This would eliminate the fallout before it even happens, allowing payments to flow through quickly to the payor without multiple rounds of attempted reconciliation. 

To learn more or have a conversation, feel free to message me here.

For more information, please visit:
Oracle Revenue Management and Billing: oracle.com/revenuemanagement
Oracle Financial Services: oracle.com/financial-services

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