Reimbursement Intelligence

Click the title above to view in your browser

What you're looking at

Reimbursements compare you to your peers over the last 12 months based on your professional claims through two view, Reimbursed which shows what payers have actually paid on your claims while Negotiated displays the rates that you have contracted with payers.

Reimbursed and Negotiated can vary for different reasons including bundling, modifiers, percentage-of-charge payment models, and other payer adjudication rules. The items at the top of each tab vary slightly.

Total opportunity applies to both tabs but represents different information. For reimbursements, total opportunity displays the amount you would have made if you were paid at the peer median per payer. The negotiated total opportunity shows the amount you would have generated if your contracted rate with a payer matched the peer rate per payer, while keeping your payer mix.

Above peers and Below peers in the reimbursed tab show a raw number of procedures where you were paid above or below the peer median for those same codes.

The negotiated tab has Rates above peers and Rates below peers. Unlike reimbursed, the figures are displayed are your the percentage of your negotiated rates with payers that fall above your peer median or below your peer median.

How it's calculated

See What You Need to Know About Medical Claims for additional background knowledge

Your peer medians are determined by providers in your specialty and geography. Jiro starts with the geography that best reflects your actual practice area, usually your CBSA (Core Based Statistical Area, used by CMS for billing adjustments) or County if a CBSA is not available. Jiro will fall back to the State level to give you an accurate comparison if there are not enough representative peers in your area. Medians are utilized to eliminate outliers. See how we build your comparison group for more information.

Reimbursement intelligence breaks down all analysis to the procedure code of your activities.

Reimbursed

Total opportunity: How much more you would have made on your claims had they matched the peer median per payer. This calculation takes the volume-weighted sum of all the differences between your median (keeping your payer mix) from your peer median per payer. Calculations are made using allowed amounts from professional claims, any institutional/facility claims, claims where you're not the rendering provider, and claims with insufficient data are excluded from calculations.

Above peers is a raw number of claims in which you were reimbursed above the peer median, while

Below peers displays a raw number of the claims where you received less reimbursement than the peer median.

Negotiated

Your Negotiated tab’s total opportunity shows how much more your claims would have generated had your contracted rates matched the peer rate per payer (keeping your current payer mix). Rates come from Transparency-in-Coverage published negotiated rates for the plans you actually bill to, and more payers will be added over time. Claims with modifiers that change the base rate are excluded.

Rates above peers is the percentage of negotiated rates that are above your peer median and Rates below peers is your percentage of negotiated rates that fall below your peers' median rate.

How to read this

The reimbursed and negotiated tabs may differ for a number of reasons including bundling, modifiers, percentage-of-charge payment models, and other payer adjudication rules. At the highest level, it is important to remember that reimbursed shows what payers actually paid on your procedure codes and activities while the negotiated focuses on the rate payers have contracted with you. The two tabs can be used together to inform you on how to approach payers or your administration regarding total opportunity for a procedure code.

Reimbursed

The reimbursed tab surfaces your unmodified claims that are paid below your peers. This could be the consequence of a lower negotiated rate with a payer, or a number of different items taking place during the adjudication process. You can check if your negotiated rate with a payer is lower than your peers' by viewing the same procedure code in the negotiated tab. If the negotiated rate is not showing the same effect, it may make sense to contact the payer or your administrative apartment to understand the adjudication decisions taking place.

Negotiated

The negotiated tab represents your unmodified claims that have a negotiated rate below your peers. If your negotiated rate is lower than your peers' for an activity, drill into the procedure code to view the associated payers and the difference in your negotiated rate vs. your peers'. For activities where you have high volume or have a large difference in your contract with a payer, it may make sense to contact the payer regarding your rate.

Common questions

I don't see any data at all. What's going on?

This may happen for several reasons. The most likely reason is that your reimbursed claims were not captured in Jiro’s database, so they aren’t shown on your dashboard. It’s also possible you don't have enough reimbursed claims in the current 12-month window yet. Both resolve as more of your claims data comes in.

These peers don't look like my practice. Are you sure this is who you're comparing me to?

If the group feels off, check that your specialty is set correctly in your profile, that's what drives the match.

I'm below my peers. Does that mean I'm under-billing?

Not necessarily. In the reimbursed view, it means that you are receiving an amount that is less than your peers for a procedure code. This may simply indicate that you have a lower negotiated rate with payers than your peers and that is being surfaced in how you are reimbursed on a procedure code. Items to consider are your volume for a specific activity, not being in a highly specialized center or big organization, and other reasons. The data is meant to start a conversation with payers about your rate for activities and does not guarantee a specific rate.

I'm above my peers. Is that going to get me flagged?

Being reimbursed above your peers indicates that for a procedure code, you are being reimbursed at a higher dollar amount than your peers. This is reflected in the negotiated view, where rates above your peers indicates that you’ve negotiated stronger rates with payers than your peer’s agreements for an activity.

Does this mean I should be coding differently?

Reimbursements focus on the rate for a code, not what code you should use. Coding decisions should focus on your patient needs, not reimbursement rates.

How current is this?

Remittance data requires a claim to be adjudicated and is subject to claims lag of around 6 months before appearing in the reimbursed tab. Negotiated rates are updated quarterly, then applied to your claims that from the last completed year.

I don't do my own billing. What am I supposed to do with this?

Sharing these numbers with whoever handles your billing. They can use the data in contract negotiations or reviewing your payer mix for you and keep them aligned on where renegotiation opportunities may exist.

Is this what I collected, or what I billed?

Reimbursed tab: This is what was actually paid as an allowed amount from your claim.

Negotiated tab: This is what you're contracted to be paid, based on published rate data. It's the rate you negotiated with the payer.

Neither number is your actual take-home revenue. But it does show you what is allowed, or what what you should get, including what the payer pays and what the patient is supposed to pay.

Limitations

• Claims data takes up to 6 months to arrive and be processed. Reimbursement intelligence highlights the previous 12 months, so recent months may be incomplete.
• Reimbursements only covers procedures where you billed as the rendering provider and the paid amount is available.
• Claims are attributed to the NPI of the billing provider listed on claims. If you bill under someone else’s NPI (e.g. a resident under an attending) your claims will be attributed to that provider. Similarly, if someone in billing under your NPI, their claims will be attributed to you.
• Negotiated rated use unmodified and unbundled rates, to create an apples to apples comparison, meaning your actual reimbursement may vary from calculations.
• Only professional claims are included; institutional or facility claims aren't reflected here. The dollar amounts you see are for what you personally bill, not what your institution bills.

Still need help?

Reach out to support using the help button in the app or by emailing support@jirohealth.com