Client engagement · Healthcare Financial Services
Healthcare Reimbursement Reconciliation
Reimbursement review depends on connecting the right contract terms with claims and payments. SOLLUS maintained data workflows supporting post-payment auditing for eight hospital systems.
- Hospital systems supported
- 8
The business challenge
Bring payment records and contract terms together.
Payment discrepancies are difficult to investigate when claims, procedure mappings, contractual pricing, and remittances are maintained separately. Analysis also needs to account for changing agreements and effective dates. Claim corrections, coding changes, and delayed payment updates can create apparent discrepancies that require validation before further review.
The engagement
SOLLUS supported a specialized healthcare services organization's post-payment insurance reimbursement auditing operations. The work supported eight hospital systems, some comprising multiple hospitals, across inpatient and outpatient workflows, and included claims associated with Medicare, Medicaid, and TRICARE.
Electronic claim files (837), payment and remittance files (835), and recurring client data updates supplied billing and payment context alongside contract terms and service mappings. QA checks helped distinguish data timing and coding differences from potential reimbursement discrepancies.
SOLLUS's contribution
The work behind the result.
- Developed and maintained Alteryx workflows for data preparation, cleansing, transformation, and recurring processing.
- Used Python for more complex processing and MySQL for database development and maintenance.
- Maintained contractual pricing information, medical procedure code mappings, and related tables as agreements and rates changed.
- Connected expected reimbursement calculations with actual payment records, supported discrepancy identification and validation, and prepared internal and external reports.
- Processed recurring payment updates and validated workflow outputs, report totals, and account-level results before posting them for audit review.
Conceptual workflow
How the information connects.
Reconciliation brings two information streams together. Current contractual terms and correctly mapped services provide the context for comparing expected and actual payments.
Contractual information
Reimbursement schedules, procedure mappings, effective dates, applicable pricing rules
Claims and payments
Service records, submitted claims, insurer remittances, actual payments
Both information streams inform reconciliation.
- 01
Prepare and process
Alteryx and Python
- 02
Manage data
MySQL
- 03
Map contract terms
Service context and effective dates
- 04
Reconcile payments
Expected versus actual reimbursement
- 05
Identify exceptions
Differences requiring investigation
- 06
Validate and report
Quality assurance and review outputs
Illustrative reporting example
Reimbursement reconciliation review
Invented providers, insurers, procedure identifiers, and dollar values illustrate an exception-review report. No patient information, client rates, or real claim records are used. A variance flags a difference for investigation; it does not establish an amount owed or recovered.
Synthetic review batch
Illustrative data — not a client report
- Claims reviewed
- 120
- Expected reimbursement
- $120,000
- Actual reimbursement
- $114,000
- Payment variance
- −$6,000
- Exceptions
- 18
Reconciliation status
| Provider | Insurer | Procedure ID | Expected | Actual | Variance | Status |
|---|---|---|---|---|---|---|
| Example Provider A | Demo Health A | DEMO-101 | $1,200 | $1,100 | −$100 | Investigate |
| Example Provider B | Demo Health B | DEMO-202 | $800 | $800 | $0 | Matched |
| Example Provider C | Demo Health A | DEMO-303 | $1,500 | $1,350 | −$150 | Under review |
Business value
A reliable foundation for investigating differences.
The workflows connected medical claims, negotiated reimbursement terms, and actual payments to support the identification and investigation of payment discrepancies. Maintained contract information and code mappings supplied the context needed for review.
Capabilities
Tools and methods
Talk with SOLLUS
Do your payment records tell the whole story?
Talk with SOLLUS about contract data, reconciliation workflows, and reports that help teams investigate differences.
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