Billing Audit Tool: Payer Rules (Beta)

This feature is currently in limited release to a select group of clients and will be rolling out to everyone in the coming months.

The Payer Rules tab allows users to create billing rules for specific payers and locations. These rules govern the behavior of billing items as they appear in Reports > Billing Audit Tool. 

Required Permissions: Super Admins 

1. To begin, click on your initials and then click Settings. 
   
2. Then click the Billing Audit Tool tab.

3. Next, open Payer Rules (Beta).

4. From the landing page, you can view, edit, delete, copy, enable, or disable all existing payer rules. You can use the Location drop-down to view payer rules tied to a specific location. 

   

   1. Edit: Click on the Edit icon to edit an already existing rule.
   2. Copy: Click on the copy icon to create a duplicate of an existing rule.
   3. Delete: Click on the red x to delete the rule. You will be prompted to confirm the deletion.

3. To add a new payer rule, click on the + Add Item button.

4. The Add/Edit Payer Rule window looks like this. 

   

   1. Payer Rule Details
   2. Billing Rules

Payer Rule Details

To begin, name the rule and add the start and end dates. Required fields are indicated with an asterisk (*).

1. Name*: Add the name of the rule to this field. We recommend using a name that makes the rule easy to identify. The field is required.
2. Start Date*: Next, set the rule's start date by clicking on the Start Date field and choosing a date from the calendar or manually typing in the date. The rule will not apply to dates of service before the Start Date. This field is required. 
   
3. End Date: This field is optional and can be used to provide a date after which the rule will no longer be applied to matching charges.
4. Active: Be sure to enable your rule by checking the Active box. If you do not enable the rule, it will not be applied to the Billing Audit Tool report.

1. Apply to All Payers: Only enable this box if you want the rule to apply to every single payer in the system, both present and future.
2. Selected Payers: Search for the desired payer. Kipu RCM integrated payers appear with an [AO-] prefix. If you need to have the same rule available for multiple payers, add them all here.

1. Select the desired location (or locations) that will use this rule. 

Billing Rules

Once you've set up the payer section, you can create billing rules.

1. To begin, click + Add Billing Rule.
2. Before we get into the actions and triggers, when you have more than one rule, you can click on the two rows of vertical dots and drag and drop the rule into the desired order. Click on the trash icon to delete a rule.
3. Rules contain a trigger which is the information that prompts the system to perform an action.

Triggers

The trigger items are the element the system looks for to prompt a specific action. 

1. To create a trigger, click + Add Trigger.
2. Click the Trigger Type drop-down.
3. Choose the desired trigger type. 
   

Trigger Types

Click on the header to expand the table.

• You can add multiple triggers to make your payer rule as specific as needed, but note that the action(s) will only occur if an item meets every single trigger in the rule.

  Trigger Type	Appearance	Description
  Ancillary Konnector		An ancillary konnector trigger will look for billing items with the selected ancillary konnector and perform the actions.  The Ancillary Konnector options will depend on the konnectors present in your instance. Options might include Avea, CollaborateMD, etc.
  Billing Provider		Rules with a billing provider trigger type will look for items with the chosen billing provider and perform the actions selected in the billing rule.
  Claim Format		Choose Institutional or Professional from the Claim Format Match field, and rules with this trigger type will apply to claims that match the selected format.
  Clinical Data		You can use clinical data rules to tie billing actions to a documented piece of data from a specific line item on an evaluation.  Evaluation Match: Choose the name of the evaluation from the list. Field Type: Choose the field type in that evaluation that contains the data you want to build the item to look for. Item Match: Select the specific item whose answer will trigger the configured action. Value Match: Choose the answer that triggers a specific action. The system will review billable evaluations for the selected field type, item, and answer and when there is a match, it will perform the action(s) in the rule.
  Codes		If you want certain actions to be taken on billing items with certain codes, make the trigger type code and add the code (or codes). Type in the entire code or enter the first two characters and locate the code in the drop-down.
  Duration		If you have a payer rule with a duration trigger type, a billing item that has a matching duration will then follow the actions attached to the rule.
  Payer		The payer (or payers) that trigger this option are the ones entered in the in the Payer Rule Details section.
  Place of Service		The place of service trigger type, when added to a billing rule, means that when a billing item has the chosen place of service, it will follow the actions indicated in the rule.
  Program		Choose a program if you want certain actions to be automatically taken when a billing item has the matching program type.
  Service Auth		The service authorization trigger type, when added to a billing rule means that when a billing item has the chosen service auth, it will follow the action(s) indicated in the rule.
  Type of Bill		The type of bill trigger type, when added to a billing rule, will

Add

The actions are the things that the system does in response to a trigger. For instance, if you need to add modifiers to certain codes, the trigger would be the specific code (or codes) appearing on an item and the action would be the system adding the specified modifier(s) based on the rule.

1. To create an action, click + Add Action.  
2. Click the Action Type drop-down. 
   
3. Choose the desired Action type. 
   

Action Types

Click on a header to expand the section. 

• You can add modifiers and the following warnings, and errors to billing items that meet the created trigger options.

  	Add a new modifier to the existing information. Once you have entered text in one modifier field, the next field will become available.
  	If you have a billing item with a required service authorization, add the Service Authorization trigger above and add this error message so that an error message will populate when a service auth is missing on a billing item.
  	If you configure a Units Maximum warning, billing items with units that exceed the maximum allowed unit added here will display a warning on the billing report.

• Use a Replace action type to replace ancillary konnectors, billing providers, codes, claim formats, modifiers, places of service, present on admission values, bill types, and unit types. 

  	To replace ancillary konnector types, use this replace option in conjunction with an Ancillary Konnector trigger.  Choose the replacement konnector from the drop-down.
  	To replace billing providers, use this Replace option in conjunction with a Billing Provider trigger. Choose the replacement billing provider from the drop-down.
  	To replace codes, use this Replace option in conjunction with the Codes trigger.  Type the replacement code(s) into the Codes Replacement field and select the correct option(s) from the drop-down.
  	To replace claim formats, use this Replace option in conjunction with the Claim Format trigger. Choose the correct replacement claim format from the drop-down.
  	To replace a modifier (or modifiers), use this Replace option in conjunction with the Modifier trigger.  Once you have entered text in one modifier field, the next field will become available.
  	To replace a place of service, use this Replace option in conjunction with the Place of Service trigger. Choose the replacement place of service from the drop-down.
  	To replace a Present on Admission value, use this Replace option.
  	To replace a bill type, use this Replace option in conjunction with the Type of Bill trigger type. Choose the replacement bill type from the drop-down.
  	To replace a duration unit type, use this Replace option.  Enter the unit number that you want to replace the original unit number with.  You can also add variable time unit increments by checking the box.
  	To replace the unit quantity type, use this Replace option.  Enter the replacement quantity unit in the field.

• Use the Remove action type to remove billable items or diagnosis codes from certain billable items (based on the triggers created).

  Remove Billable Items

  	Choose Billable Items from the Remove Type drop-down to remove the items that meet the trigger criteria set up in the rule.
  	If needed, click + Additional Properties.
  	Additional properties allow you to edit which elements are included or excluded. In this instance, you can include or exclude a Do Not Bill reason. Currently, it is excluded.
  	Click on Do Not Bill Reason to include it, then click Submit.
  	Now there is a field to choose a specific Do Not Bill Reason.

  Now, items that meet the trigger criteria will remove the billable item, send it to Do Not Bill, and set the Do Not Bill reason to the one selected from the drop-down.

  Remove Diagnosis Codes

  	To remove specific diagnosis codes from billable items that meet the trigger criteria established in a rule, choose Diagnosis Codes from the Remove Type drop-down
  	Then, in the Diagnosis Codes Configuration field, begin typing the code (or codes) that you want removed and select it from the drop-down.

  Now, items that meet the trigger criteria will remove the chosen code (or codes), from the billable item.

• This action item allows you to create custom and Office Based MAT bundles.

  Note that because each rule is much more customizable, if you need items to require a service auth, use the Add > Warning/Error > Requires Service Auth action option.

  Office Based MAT

  You can bundle Office Based MAT services by Duration, Services, and Phases.
   

  Duration

  	When you choose Duration, billing items that meet the trigger type stipulations will bundle by duration in a monthly billing period.
  	You can also include additional items to refine which elements are included in the bundle.

  Services

  	When you choose Services, billing items that meet the trigger type stipulations will bundle by services in a monthly billing period.
  	You can also include additional items to refine which elements are included in the bundle.

  Phases

  	When you choose Phases, billing items that meet the trigger type stipulations will bundle by phases in a daily billing period.
  	You can also include additional items to refine which elements are included in the bundle.

  Custom

  You can also create custom bundles by choosing Custom in the Bundle Type field.

  Daily

  	When you choose the Daily billing period option, billing items that meet the trigger type stipulation will be bundled by daily billing period.
  	Add additional items to refine which elements are included in the bundle.

  Weekly

  	When you choose the Weekly billing period option, choose the billing week option that works best for your organization. Billing items that meet the trigger type stipulation will be bundled by the chosen billing week period.
  	Add additional items to refine which elements are included in the bundle.

  Monthly

  	When you choose the Monthly billing period option, billing items that meet the trigger type stipulation will be bundled by month.
  	Add additional items to refine which elements are included in the bundle.

  Rolling Days

  	When you choose the Rolling Days billing period option, enter the number of days that should be bundled together. Billing items that meet the trigger type stipulation will be bundled by the number of days added.
  	Add additional items to refine which elements are included in the bundle.

  Admit To Discharge

  	When you choose the Admit to Discharge billing period option, billing items that meet the trigger type stipulation will be bundled by Admit to Discharge.
  	Add additional items to refine which elements are included in the bundle.