A hospital’s machine-readable file (MRF) lists standard charges for its items and services, including cash prices and rates negotiated with insurers. For a negotiated rate, a reviewer needs to know which service, payer and plan it belongs to.
ClearCare Readiness & Proof is being developed with hospital compliance and revenue cycle teams in mind. It helps them review a candidate file, resolve questions and keep a record of how they chose the version to publish.
An outpatient MRI row lists a negotiated amount. The source mapping could refer to either of two plans.
Basis
Supplemental ClearCare review
Owner
Hospital revenue cycle team
Decision
Hold this version for clarification.
How the team resolves it
The owner checks the contract mapping with the file vendor. The reviewer compares the corrected row with the source and records the vendor’s response, the file version and the reason for closing the issue.
The review process
From candidate file to publication decision.
Establish the starting file.
Identify the candidate from the hospital’s vendor or internal team and preserve its version. Keep findings from the Centers for Medicare & Medicaid Services (CMS) validator separate from ClearCare’s supplemental checks, so reviewers can see the basis for each issue.
Put each question with an owner.
Route a mapping question to revenue cycle, a file-format problem to the vendor, or a publication question to the web team. Record the source evidence, response and disposition against the file under review.
Document the hospital’s decision.
The hospital chooses which version to publish. Where the engagement includes a public-file check, the team compares what was available at the recorded URL and time with the version the hospital designated.
We’re preparing a limited design-partner program for hospital teams. The proposed engagement lasts 30–60 days. The hospital and ClearCare agree on the file, participants and review scope before work begins. The initial scope excludes protected health information.
At the end of the review, the hospital can trace an issue from the original file through the owner’s response to the decision about publication. See what the hospital receives.