Medicare and Medicaid repricing system enables healthcare payers to efficiently manage healthcare provider data and automate claims pricing by leveraging its adaptive, rules-driven architecture. Medicare claims repricing can significantly lower, pre-negotiated rates which providers in the healthcare networks have already agreed.
What is Medicare Claims Repricing?
Medicare claims repricing is the application of the contract terms to the billed charges. Contract terms indicate the contract between the hospital system or physician practice and the insurance network, and the billed charges are from the hospital system or the physician group.
How does Medicare Claims Repricing Work?
There are multiple ways for Medicare claims repricing. Many claims repricing strategies exist for different types of plans. Among the most frequently used solutions is the preferred provider organization (PPO) for health insurance claims repricing. In this solution, a fixed fee structure is applied to medicare claims, which enables providers to restructure and discount payable claims. This is an effective method and vital to remittance efforts.
Upon receiving a Medicare claims form, the health insurance companies adjudicate if the person is eligible, or the service or record service is eligible, if it is too late for timely filing, or required prioritization, etc. It gets to the whole process. Then, it needs to be repriced, because the original claim has the billed charges on it, and then it’s repriced to the allowed amount. And, then the allowed amount is divided between the patient’s responsibility and the plan’s responsibility.
As regards the patient responsibility, it needs to be adjudicated so that if there is any due, the patient needs to pay that back to the claim provider, and then the plan responsibility adjudicated to ensure if there is any due, the plan responsibility needs to pay back to the provider. And that directly comes to the insurance carrier or insurance group or to the self-funded employer through the claim provider.
Now, here is the key, the contract terms or Medicare repricing is performed on the basis of case rate, percentage of charge discount, per diem, or what the insurance companies reimburse a set amount or expense per day, carve out that is a specific line of payment, etc. The total amount of expenses has to be within the allowed amount, which is the true cost of healthcare and the whole amount of price transparency.
Then comes the billed charges, which are described as the fictional amount that nobody pays. So the group charges of this amount are confirmed through the chargemaster that is a list of all of the prices of every single service at the hospital, such as 30-minute overstay costing $1000 bucks, etc. and all these add enough to form the billed charges.
How Do Third Party Administrators (TPA) Perform Repricing?
TPAs leverage self-service Medicare and Medicaid solutions for repricing to accurately adjudicate the bills and batch claims into the system. By using a solution like CMSPricer, a SaaS-based Medicare repricing system, batching claims into the system becomes easy, and importing or exporting a claim file for re-pricing is also accomplished so easily with the custom interface of CMSPricer.
CMSPricer is designed to meet all stringent CMS Medicare claims accuracy requirements for auditing claims from over 50 Medicare Advantage plans. By leveraging the advantages of CMSPricer SaaS-based tool and interface, TPAs, Payers, auditing firms, BPOs, etc. can effectively batch process with ease and precision.https://cmspricer.com/.
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