GoRev Contract Management
Case rates! Groupers! Waterfalls! Per Diems! Who's on first? What's on Second?
This GoRev module was introduced in version 2023.06.12 and will facilitate loading of your healthcare insurance carrier contracts, comparison of charge master to your contracted rates, insurance claim payment variance workflows, and financial performance analysis of your contracts.
Note: Healthcare contracts are rarely simple (almost seems intentional). If you should need assistance with loading your contracts please do not hesitate to reach out by submitting a ticket with:
- Your original signed agreement(s)
- We need this to identify and implement logic for any special scenarios such as waterfalls, carve outs, change in the order of rate type application (we've seen a lot of games)
- We need the signed agreement as this will have the effective dates
- All supporting fee schedules and documents
- Examples: Spreadsheets of rates by procedure, DRG weight spreadsheets, market fee schedules, carve out item lists, etc.
Configuring and assigning contract codes
Navigate to Admin --> Configuration --> Lookup Tables
Select the ContractCodes lookup list and click New Item. Naming convention is up to you. We suggest naming the contracts in a way where you can quickly see the GoRev Facility, the applicable year, and the payer. This list is server wide and will be accessible in all of your GoRev Facilities.
Assign contract codes to carriers and plans
Navigate to Carriers and Plans within the Admin --> Configuration menu (Insurance Carrier Management)
Select a contract code (populated from the lookup list entries you made above)
If a contract code is applied to a plan it will be utilized and any carrier applied code will be ignored. If no contract code is applied at a plan level the carrier code will be utilized.
Carrier Representative
These are optional fields and will help you keep track of your key contacts at insurance carriers related to the specific contract.
Key Dates
These fields are also optional. They will populate fields on various reports within the system but will not impact actual application of contracted rates to specific claims. The dates within your actual contract terms uploaded are utilized to assign to specific claims (see further below)
Files / Notes
Optional fields allowing you to upload all contract files including the actual signed agreements along with all supporting documents. Notes allow your team to place any additional important details related to the specific contract.
Be aware, anything uploaded here can likely be accessed by many of your GoRev users (any user with permissions to carriers/plans).
Importing Contract Terms
Your contract terms will be extracted from the actual contract agreement and all of its supporting documents into a csv in the standard format below. This template CSV can be downloaded here: GoRev Contract Management Import Template.csv
Column Name | Required | Supported Values | Details |
ContractTerm | Yes | 1 = Fee_Schedule 2 = Case_Rates 3 = Carve_Outs 4 = Per_Diem 5 = Per_Visit 6 = Groupers 7 = Groupers_Waterfall 8 = Per_Unit 9 = DRG 10 = BilledCharge | |
StartDate | Yes | Timestamp mm/dd/yyyy hh:mm | The first date of service (admit date) of when this contract term should be applied |
EndDate | Yes | Timestamp mm/dd/yyyy hh:mm | The last date of service (admit date) of when this contract term should be applied |
BillingCode | Yes | Alphanumeric (ties to the procedure code in your charge master) | The procedure code (all types supported) |
Rate | Yes | Decimal 1342.12 | The contract rate for the procedure before any other logic is applied such as waterfalls. |
CaseLevelPayment | No | Boolean 0 = Off 1 = On | Toggling this on will cause the system to consider this contract term to be a case rate. Case rate logic will be applied causing other procedures falling within the same case rate to be bundled. |
ContractCode | Yes | Alphanumeric You set this in Lookup Tables | This is the contract code you setup in lookup tables (see above) |
GrouperCode | No | AlphaNumeric | Provide a name for each grouper level within your contract. This is typically set simply as Grouper 1, Grouper 2, Grouper 3, etc. |
Modifier1 | No | Alphanumeric 2 digits | Any standard modifier such as TC, 50, RT, LT |
Modifier2 | No | Alphanumeric 2 digits | Any standard modifier such as TC, 50, RT, LT |
PercentageOfCharge | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this contract term will calculate based on Charges * this specified percentage. |
ChargeThreshold | No | Decimal 1342.12 | Specifying this will implement a threshold that must be met in order for this contract term to be considered allowable. Any charge below the threshold will be shown in Non-Allowed charges. |
RateSource | No | Alphanumeric | Allows you to describe the source of the rate. We recommend naming these with the actual rate source document. As an example, CIGNA RBRVS.xlsx or BCBS Ancillary Market Fee Schedule.xlsx. This name will show up in the Contract Allowable screen within GoRev when this contract term is applied. |
MaxUnits | No | Integer | Specifying this will cause the system to apply no more than this number of units to the contract term. For example, if your team bills 99 units and the maxunits set here is 1, then only 1 unit will be calculated as the allowed. |
Waterfall1 | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this waterfall will be applied to the FIRST of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7 |
Waterfall2 | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this waterfall will be applied to the SECOND of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7 |
Waterfall3 | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this waterfall will be applied to the THIRD of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7When specified this waterfall will be applied to the FIRST of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7 |
Waterfall4 | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this waterfall will be applied to the FOURTH of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7 |
WaterfallGT4 | No | Decimal Percentage 100% = 1 50% = 0.50 | When specified this waterfall will be applied to the ALL PROCEDURES 5th LEVEL AND UP of multiple procedures found with the same GrouperCode. Note, this will only apply to contract terms with a GrouperCode that are set to ContractTerm = 7 |
This CSV will be imported into GoRev utilizing the ContractTerms Data Import Utility. Initially, we will be performing this action for all clients. Once we work through initial data loads we will release access for you to do this on your own.
Accessing the Patient Claim Level Contract Management UI
Navigate to the Financials Patient Financials area within GoRev
Click on Contract Allowables
A new window will pop up as shown below.
Calculation summary will provide the claim's total calculated allowable per your loaded contract terms. It also provides a variance compared to actual allowable posted from the specific insurance carrier.
Allowed Charges provides a procedure level listing of allowed rates. Allowable Source = the rate source you configured when importing contract terms. Allowable Rate is the rate after relevant contract term type logic is applied (groupers, per case, etc). Grouper waterfall will show which waterfall tier the grouper contract terms align with and will show the allowed after the waterfall has been applied.
Non-Allowed Charges provides a procedure level listing of all items that have no allowable per your contracted terms. These include items that were grouped into another contracted term and items that simply have no allowable rate listed per your contract.
Both the top and bottom pane can be exported to PDF or Excel (useful for submission with appeals)
Accessing contract management reports
Navigate to the Reports area within GoRev. Search for Contract Management and you will find a series of reports. This will expand as we integrate the contracts into more processes.
Claim Level Past 90 Days by DOS = Default view showing the allowed rate at the claim level for admit dates within the past 90 days. AllowedDelta will show you the difference between the calculated contracted allowable and actual current allowable by claim.
Claim Level By Date Range = Allows you to specify the admit date range and returns claim level allowed rates for accounts where an active contract code was applicable.
Item Level By Date Range = Allows you to specify the admit date range and returns procedure level allowed rates for all accounts where an active contract code was applicable. SingleQtyOpRate will show you the current contracted rate for the procedure. Note: it is impossible to calculate actual allowable at the procedure level as claim level rules will be applied upon final adjudication. Contract Terms such as groupers, case rates, waterfalls, etc will alter he final allowable amount by procedure.
Contract to CDM Comparison = Compares your current charge master rate for each procedure to the highest found contract term rates. It will return one contract term rate for each contract code and display the delta as well as identify procedures where no contract terms apply. These could be truly non-covered procedures or could be instances where additional contract terms need to be uploaded. IMPORTANT: You should at a minimum run this report for all contracts to identify any procedures priced below your contracted rate. Majority of health insurance contracts will allow the LESSOR of your charge or the contracted rate. ContractRateDelta field in this report will show this (negatives are where you are charging less than contracted rate)
Contract Modeling = Allows you to specify a contract code and an admit date range. It will then apply the contract code's contract terms against all accounts within the specified admit date range regardless of Carrier or Plan. From there you can filter to only look at specific carriers or plans within the data grid. A delta compared to current allowable is provided. This report will help you model proposed contracts and forecast contract revenue impacts.
Listing of all Reports within the Contract Management tile:
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.