The Expected Reimbursement values within the Payment Detail by Appointment v3 and Claim Transaction Detail reports are not representing the correct rates.
Currently, the values pull based off what the expected reimbursement was calculated at the time of claim creation. Due to the nature of contract updates, contracts can take 3-4 months to update in the new calendar year, but are backdated to the beginning of the year. These claims do not need to be voided and reprocessed as corrected claims, as the payer already updates them.
However, even if the fee schedules are backdated with effective ranges to the beginning of the year, the column of Expected Reimbursement does not pull based off the effective range, instead it pulls off of expected at time of claim generation.
Requesting this to be updated to allow for more accurate payment reporting at expected reimbursement.
Scenario Below:
Payer: Aetna
Date of Service: 1/1/24
Claim Creation Date: 1/3/24
Expected at time of Claim Creation: $350
2024 Updated Expected: $375
2024 updated Expected Reimbursement Date: 3/1/24
Effective Date of 2024: 1/1/24
Report Generated: 6/1/24 for DOS 1/1/24-3/31/24
Goal: When running the report retrospectively, the Expected Reimbursement column will be based off the effective range of the fee schedule for the DOS range selected.
