The recent California Department of Health Care Services (DHCS) amendment to the AB 118 bill has Medi-Cal managed care health plans working overtime implementing this bill. This provision is increasing Medi-Cal rates for eligible contracted providers to equal no less than 87.5% of the lowest Medicare rate who supply treatment for certain Medi-Cal services rendered on and after January 1, 2024. This regulatory change requires system updates such as: coding, pricing, benefit updates, and in some cases, time-consuming re-adjudicated projects.
TRI Pricing Regulatory Challenges:
The TRI Pricing is often based on utilization and various payment methods resulting in claim system configuration limitations. Claims are deferred to manual process to reflect the higher contracted rate or the new Targeted Rate Increase (TRI) pricing for specific date range and to exclude certain codes from provider payment and pricing reduction for certain modifiers. This method adds another layer of complexity and administrative burden.
SymKey's Automated Solution:
Using SymKey robotic process automation (RPA) you can create a query to automate TRI Pricing claims by using different parameters and business rules to help identify and automate the claims. Parameters can include but are not limited to:
- Comparison Logic: Automated system to compare 'EZCAP Allow Amount' with 'TRI Fee Schedule,' ensuring the greater value is used for reimbursement.
- Code Logic: Include procedure code, modifier codes, and provider contract status.
- Adjustment Code Implementation: Add Adjustment Reason Code "223" to claim lines needing updates due to TRI rate adjustments.
- Manual Review Flags: Claims with specific modifiers flagged for manual review to guarantee the correct application of the TRI fee schedule.
SymKey Statistics, Impact and Results:
Quantitative Outcomes:
- Adjusted open claims: 1,153 with 1,173 lines.
- Reprocessed paid claims: 5,374 with 5,564 lines.
Operational Enhancements:
- Enhanced control by providing tools for selecting specific claims and date ranges for reprocessing.
- Developed custom reports and queries for effective management of claims.
- Reduced manual workload and error rates.
- Minimized financial disruption by ensuring accurate and timely reimbursements.
The seamless integration of automated tools minimized errors and optimized reimbursement processes, illustrating how technology can be leveraged to turn regulatory challenges into operational victories.