Medicare billing can be arduous and Medicare claims repricing can be challenging. If they are put together and one works on them without proper training, the result can be a loss of revenue.
With the use of an easy-to-use, SaaS-based medicare claims repricing tool, an organization can mitigate the entire claims repricing process and optimize spending. However, understanding claim repricing is crucial.
What is Claim Repricing?
Claims repricing is simple in theory, but complex in practice. It is the application of agreed upon or contracted payment rates to medicare charges. The provider submits a claim and includes line items for each service provided.
The payer assesses the claim validity and reprices the claim according to the agreed upon rates. It is known as the allowed amount, which is divided into patient and plan responsibility for paying the provider.
The contracted rates can be a few things, such as a signed contract agreement or just an acceptance of a payment policy, which is like medicare reimbursement rates or payment method. By accepting a claim, the provider agrees to adhere to all payment policies of that payer and reimburse based on Medicare rates.
Medicare Reimbursement Rates
Medicare reimbursement rates refer to the amount of money that Medicare pays to doctors and other healthcare providers when they provide medical services to a Medicare beneficiary. It is also referred to by Medicare as the Medicare Physician Fee Schedule (MPFS) that tends to vary based on the service fees or item costs provided.
Medicare reimbursement rates on average range roughly 80% of the total medical bill. However, not all types of providers are reimbursed equally. For instance, clinical social workers receive 75% while clinical nurse specialists are reimbursed at 85% for most services.
By using the framework of medicare prospective payment system (PPS), medicare advantage plans share the risk with their provider network. It makes each group accountable for the part of risk that they can effectively manage. With PPS medicare reimbursement rates in which medicare payment is made based on a predetermined and fixed amount.
Payers derive payment amounts for a particular healthcare service on the basis of the classification system of that service, for example, diagnosis-related services for inpatient hospital services. The medicare reimbursement rates are allowed separately for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, skilled nursing facilities, etc.
How to Take Control of Medicare Claim Repricing?
Medicare claims repricing is simple until a Medicare Advantage plan is accepted. Upon the acceptance of medical claims, the Medicare Advantage plan providers start working on the pricing of healthcare expenses. Since payers may often present claim repricing differently, it is necessary for providers to communicate with payer representatives on their payment processes. It will guarantee that your organization is paid the correct amount for all services completed and will result in less time assessing remittance advice in the future.
How to Streamline the Medicare Claims Repricing Process?
By using a SaaS-based solution for medicare repricing, payers can streamline the workflows and drive efficiency with advanced analytics. See into the features of CMSPricer, which empowers payers, PPOs, TPA’s, BPO’s, self-funded employers and auditing firms.
CMSPricer prices all PPS types of institutional and professional claims including claim editing for Referenced Based pricing. With the Medicare and Medicaid PPS reimbursement solutions, organizations can benefit from automated regulatory content updates to more accurately claim repricing. CMSPricer is designed to help its users to stay current with all methodologies and policy and rate updates and save time and money with a comprehensive Medicare and Medicaid repricing solution.
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