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Why are charge reconciliation and business rules meaningful? When you’re running a charge reconciliation, the root goal is to find missing charges or missing encounters that you need to bill. There may be charges that weren’t charged. Yet, the primary purpose of charge reconciliation is to find things that never entered the billing system. That never somehow came across either from scheduling or whatever the clinical system is into the billing system. Therefore, they go poof and disappear into the void.

Locate the missing charges

When you’re doing a charge reconciliation, though, there will constantly be something that you find going to throw you a little bit off the hook. Some charges should be missing. Some things should not be entered into the billing system. It could be that there are specific procedures you don’t bill for and maybe some things on a global period. Ideally, you would document those and not bill them. There could be something Medicare doesn’t pay. 

There could be all kinds of different reasons. The provider has specific rules. They said, “Okay, we don’t bill this. We bill this instead” or “Instead of these three things, we’re going to bill only two of them,” or whatever the case might be.

Look for false positives

When you run your charge reconciliation, you will get a list and output that is, in theory, all of the patient counters missing and the charges, but there will be some false positives in there or type I errors. In other words, something is said to be missing when it’s not missing.

Part of your reconciliation might include checking for missing records and not just encounters, like missing individual procedures, CPTs that could have been changed or dropped or eliminated, or whatever it might be. 

Standardize the rules

Many of those situations could be where a doctor knows something clinically. You don’t follow payer policies or internal billing policies, or you don’t bill for something, or you bundle it in, or whatever the case might be. This means that you need to include all of those rules in your analysis.

As we’ve discussed in some other podcasts and articles, some of these rules might be in the billing department or the billing organization, in somebody’s head. They might be written down in Excel spreadsheets. They might be handwritten notes. There can be many different ways that these are documented or not even documented, but known. However,  it’s unlikely there’s going to be a format that a software developer or even just an analyst could use to code into a rule engine.

Document one set of rules for charge reconciliation

First, of course, always make sure that those rules get written down and see our other discussion about conditional logic, which talks about how to do it and do it in a format that you can use for everybody else.

Here is the interesting part. When you’re doing a charge reconciliation to find missing encounters or missing charges, it’s crucial to put all of those rules into the analysis. For instance, your charge reconciliation will produce so many false positives, basically, errors, that no one will take it seriously. If no one takes the charge reconciliation seriously, it will collapse and fall apart. Moreover, there’ll be a lot of revenue lost because there won’t be support for that process. In addition, you won’t have an operational need.

Final point

Make sure that you follow through and do all those things. Take time to find the rules, document the rules, follow the conditional logic, and write them down. Further, get an analyst or a software developer to put it into an Excel format or whatever it is that you’re using. Why? So that you can successfully do charge reconciliation and have confidence that it is correct and that you then uncover what you haven’t billed so that you can get it billed out the door and get some free money.