GoRev Integration with OpenCare Data
As of GoRev version 2023.08.04 we have integrated our OpenCare Data platform with GoRev. This guide will go over what you need to do in order to configure your locations and carriers/plans in order to pull the correct OpenCare Data rates. It will also go over the new UI's where this information is visible in GoRev and the new standard report set.
If you aren't familiar with our new OpenCare Data platform we launched late 2022 feel free to read up on here https://opencaredata.com/
Or checkout a guide on how to use it here: OpenCare Data User Guide
How the GoRev API To OpenCare Data Selects QPA Rates
The GoRev API follows a step by step process to select the QPA rates most closely aligned with the CMS calculation methodology defined here: CMS 45 CFR 149.140 QPA Methodology.pdf
A link to this document is here: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/CAAQualifying-Payment-Amount-Calculation-Methodology.pdf
Step 1:
The API looks up the MSA (metropolitan statistical area) associated with your service location's zipcode. If you'd like to see this in action, feel free to use our online MSA lookup tool here https://opencaredata.com/MSALookup.aspx
Step 2:
The API queries OpenCare Data for each billing code on your claim, using the taxonomy code(s), rate type (institutional/pro), and carrier/plan payer sources you have configured per the guides below. The query applies a negotiated rates only filter. It selects the median rate of all provider rates returned.
IF 5 or less rates are returned using this criteria the API runs a new query at the state wide level.
IF 5 or less rates are returned at the statewide level the API runs a new query at the MSA level using a Fee Schedule rate filter.
IF 5 or less rates are returned it runs a Fee Schedule rate filter search at the statewide level.
Configuring your GoRev to retrieve OpenCare Data Rates
First, update your locations with the taxonomy codes relevant to your specialty. For example, institutional emergency rooms and hospitals may want to use taxonomy code 282N00000X - General Acute Care Hospital. Go to Admin --> Configuration --> Locations --> Click into the Open Care Data tab.
Then specify the taxonomy code(s) relative to your location and specialty. As an example, for a free standing emergency room or hospital we'd recommend selecting General Acute Care hospital at a minimum and potentially adding additional hospital types should they be relevant.
NOTE: Selecting taxonomy codes related to professional services or unrelated specialties can impact your QPA calculation.
Next, select the provider type. Facilities will typically select Institutional (you bill on a UB04) and Doctors/Professional groups will typically select Professional (you bill on a CMS1500). There are scenarios where you may want both rates just know as both rate sets are pulled in it will impact how the Median, Average, and percentile OpenCare Data stats are calculated.
Second, attach OpenCare Data payer sources to your Carriers / Plans within GoRev.
The system will then begin to request OpenCare data Median and 80th percentile rates for all procedures you have marked as Active within your charge master. This process can take up to 48 hours depending on the size of your charge master.
OpenCare Data in Financials UI
A new row of claim level financials is now visible in the Financials UI.
Allowed Amount = The total insurance payments plus patient charges
OpenCare Data Median = The total of all OCD Median rates for all procedures on the claim. Keep in mind, this median value is filtered to the MSA of your location and the Taxonomy you set in Locations along with the OCD payer source you set on the carrier/plan above. This OCD Median rate, if configured correctly, should align with CMS' QPA calculation methodology specified here: CMS QPA Methodology.pdf
Median Delta = OpenCareData Median - Allowed
Contract Allowable = The total calculated to be allowed per your loaded contract for the primary payer on this claim. See GoRev Contract Management for more details.
Under Allowed = Contract Allowable - Allowed Amount
We have also added OpenCare Data median information to the Contract Allowables UI (based on our GoRev Contract Management system). This may help you evaluate your negotiated contract rates against actual median in-network contract rates for all other same specialty providers in your area.
OpenCare Data in Print Forms
You can now use OpenCare Data statistics directly within your dynamic print services forms. For example, you could create an appeal based on these rates with specific verbiage per the No Surprises Act. The following fields have been added to facilitate the No Surprise Act QPA Appeal form shown below.
Clicking Generate PDF will yield this: No Surprise Act Underpaid QPA Appeal Template.pdf
OpenCare Data in Reports
Three new standard reports have been introduced as of 2023.08.04.
OCD Charge Master Analysis will compare the OpenCare Data Median rate against your charge showing both a delta and multiple.
OCD Variance Summary will show a claim level set of financial information with the total charges, allowed, OCD median, and deltas. Useful for determining which accounts paid less than the median rate.
OCD Variance Detail will show the same financial information as summary but at a charge item level
GoRev Support Team
If you have any questions, concerns, or problems regarding this GoRev Tutorial, please contact the GoRev Support Team by submitting an IT Support Ticket, by phone at 1-(317)-794-3900, and/or by email at ask@gorev.com.
Note: If possible, always submit an IT Support Ticket detailing any problem that you are experiencing within GoRev. This will give GoRev Support Agents access to additional information that will help expedite the resolution of your issue. If you are unsure how to submit an IT Support Ticket in GoRev, please see theIT Support Ticket Creation for assistance.