Pearce J W
Dan Grauman Associates, Inc., Bala Cynwyd, Pennsylvania, USA.
Healthc Financ Manage. 1999 Dec;53(12):31-4.
Integrated delivery systems (IDSs) should conduct annual audits of payers' settlements under risk contracts to verify that the payer attributed the appropriate amounts of revenue and charged the appropriate claims expenses to the IDS. In particular, IDSs should verify that payers calculated revenues and expenses based on consistent member counts and that the determined commercial revenue was based on the actual premiums paid. IDSs also should determine whether payers have used appropriate demographic factors and countywide rates as a basis for determining Medicare revenue, charged the IDS for claims only for valid members, paid capitated providers the correct capitation amounts, and used appropriate historical data to estimate the amounts of incurred-but-not-reported claims attributed to the IDS.
整合式医疗服务体系（IDSs）应对风险合同下支付方的结算进行年度审计，以核实支付方是否将适当的收入金额归属于IDSs，并向IDSs收取适当的索赔费用。特别是，IDSs应核实支付方是否根据一致的会员数量计算收入和费用，以及确定的商业收入是否基于实际支付的保费。IDSs还应确定支付方是否使用了适当的人口统计因素和全县费率作为确定医疗保险收入的基础，是否仅就有效会员的索赔向IDSs收费，是否向按人头付费的提供者支付了正确的人头费金额，以及是否使用适当的历史数据来估计归因于IDSs的已发生但未报告的索赔金额。
