Payment Integrity
What is March 2021?
A record of service provided to an eligible, enrolled member of Banner by a registered provider and submitted to AHCCCS, CMS and UHC.
What is an Encounter?
The accounting entry used to record recovery fees paid
What is a journal entry?
This three-letter acronym stands for the Hierarchical Condition Category model used by CMS for risk adjustment.
What is HCC?
This Payment Integrity Team member wanted to President of the United States.
Who is Charlie?
Gloria, Joanne and Klementina are the longest running staff in Payment Integrity at this many years.
What is 20 years?
Banner enrolled Medicaid member exceeds their limits for an IMD stay
What is Contract Type N?
No matter how many emails we send, reminders we give, or meetings we hold... this is still the max lookback period from original paid date for all LOBs.
What is one year?
This is the number of times per year that chronic conditions must be documented in patient encounters to count toward risk scores in the CMS HCC model.
What is annually (or once)?
This Payment Integrity Team Members likes to bake in their spare time.
Who is Ryleigh?
Three individuals came to Banner from this organization as part of a contract option to re-badge employees to retain subject matter expertise.
What is Evolent Health?
CMS requires AHCCCS to submit progress reports on the encounter data collection process. AHCCCS must take appropriate action to correct deficiencies identified in the collection of encounter data and enforce financial penalties on Contractors that are not in compliance with data collection requirements.
What is the Annual Data Validation Study?
A Provider disputes a recoupment-this process may follow.
What is an Appeal?
This term describes the process where Medicare Advantage plans must ensure that chronic conditions are documented each year to maintain accurate risk scores.
What is recapture?
This Payment Integrity Team Member is a rewards member with Dutch Bro's.
Who is Margaret.
Most other health plan organizations include these two departments as part of their Payment Integrity organization.
What is Pre-Payment Review & Fraud, Waste, and Abuse (FWA).
Stop-loss mechanism to provide contractors with partial reimbursement for specified contract service costs incurred by a member.
What is Reinsurance?
When a Provider returns money, it is recorded as this.
What is a refund?
This numerical value, calculated by combining HCC weights and demographic factors, represents the predicted cost ratio of a beneficiary compared to the average Medicare population, where 1.0 equals average expected costs.
What is a risk score?
This Payment Integrity Team Member lives the farthest away in this state.
Who is David and Georgia?
These three departments are typically critical dyad partners with Payment Integrity.
Who is IT, Contracting, and Clinical Policy (Medical Management).
This type of CMS encounter includes evaluation and management codes, procedures, and diagnoses from physician office visits
What is a professional encounter?
When another insurer is identified as primary before payment is made, preventing the health plan from paying incorrectly.
What is cost avoidance?
This specific type of interaction coefficient in the HCC model provides additional payment weight when a beneficiary has multiple severe conditions across different body systems, recognizing the compounding complexity of care.
What are disease interactions?
This Payment Integrity team member reached their Pearl Wedding Anniversary symbolizing 30 years of marriage.
Who is Kim?