Medicare & Medicaid Revenue Reconciliation

Accurate and timely reconciliation of Medicare and Medicaid enrollments and payments

Medicare and Medicaid reconciliation is complex. Data issues can cause Plans to lose up to 20% of their monthly capitation payments as they struggle with large volumes of CMS data and navigate ever-changing payment methods and regulations. Revenue360 helps Plans ensure regulatory compliance, avoid penalties, and stop revenue loss and by better managing financial data and streamlining how state beneficiary enrollment and payment information are reconciled.

Revenue360 for Medicare

Revenue360 for Medicare Advantage Plans adds intelligence and automation to the reconciliation process. The fully automated solution captures various Part C and Part D payments (including member premium for SSA withholding), applies lump sum retroactive payments split across months, calculates expected monthly payments and reconciles the data each month. Plan administrators can then use the platform’s intuitive web portal to research, track and analyze open discrepancies and maintain an audit trail of resolutions.

Revenue360 for Medicaid

Revenue360 helps Plans manage and complete the attestation process on schedule while enhancing their operational efficiency and mitigating risks. Plans can generate reports that identify and correct discrepancies in enrollment, demographic information, and payment data to proactively address and resolve any issues and ensure the accuracy and integrity of their financial-management process. Organizations can also track open discrepancies and maintain an audit trail of resolutions.

Advanced Reporting

Each month, Revenue360 automatically generates more than 40 standard reports and data extracts to help Plans monitor trends and understand discrepancies. These reports include payment summary, balance brought forward, discrepancy aging, suspense amount, and prescription drug event (PDE) activity. Revenue360 also includes an add-on recon BI analytics tool for data visualization and ad-hoc analysis and reporting.

Revenue360 Supported Feature	Medicare Advantage (MA)	Medicaid
Intelligent Automation	Captures various Part C and Part D payments and includes member premium for SSA withholding. Automatically applies lump sum retroactive payments split across months. Calculates the plan’s expected monthly payments.	Uses a unique reimbursement model. Typically makes payments to providers for Medicaid beneficiaries on a fee-for-service basis. Facilitates reimbursement based on a predetermined fee schedule or negotiated rates. Uses the 834 file format to integrate with Medicaid systems and perform required reconciliation.
Actual Vs Anticipated payments	Resolves discrepancies between payments received by MA plans and calculated amounts based on risk adjustment and other factors. Helps finance department get an accurate picture of money owed to or from CMS.	Helps finance department get an accurate picture of money owed to or from states.
Automated processing of Inbound files	Enables automated processing of files directly from CMS or passed along from the customer, as well plan membership files from different sources. Manages data from both paper and electronic provider submissions for reimbursementent.
Flexible Reconciliation Frequency	Enables MA plans to process files within monthly reconciliation timeframe or as per health plan requirements.	Accommodates weekly, biweekly, or custom frequencies
Discrepancies identification and resolution	Integrates with member management systems to identify member- and contract-level issues. Assists plans in understanding how discrepancies impact payments, and offers resolutions or otherwise acts on discrepancies.
Reporting & Oversight	Supports CMS compliance requirements including financial reporting and audits.	Provides state-specific reports including financial reporting, program integrity, and audits.
Meets Regulatory Compliance requirements	Maintains compliance with CMS 45-day attestation requirement. Helps identify demographic and financial differences between plan and CMS data.	Implements according to the unique regulations, reporting requirements, and date submission guidelines of each state's Medicaid program.
Standard Reports	Automatically generates more than 40 monthly reports and data extracts to help plans monitor trends and understand discrepancies, including reports on payment summary, balance brought forward, discrepancy aging, and suspense amount. Provides add-on recon analytics powered by a BI tool for data visualization and ad-hoc analysis and reporting by the end users.
User Friendly web portal	Provides simple, intuitive navigation to research and analyze discrepancies, keep close track of open discrepancies for resolution, and maintain an audit trail of actions taken to resolve discrepancies.
Medicare Part D Reconciliation	Enables manually entry of direct and indirect remuneration (DIR) into PDE annual reconciliation tool. Tracks online total CMS paid versus estimated low-income cost sharing, reinsurance, risk, and coverage gap payments.	Not Applicable