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Medicare Claims Editing Simplified and Streamlined to Save Your Time and Investment

Medicare claims repricing is the application of the contract terms to the billed charges between the hospital or the physician practice and the insurance network. And the bill charges are from the healthcare facility or the physician group. 

As the “claims” is received, it is sent for adjudication to verify certain claim criteria, and then it needs to be repriced because the original claim has the bill charges on it, and then it is repriced to the allowed amount. And then the allowed amount is divided between the provider and the plan. 

The claims are submitted for both CMS repricing at Medicare rates and edited to identify and eliminate errors and anomalies, fraud and abuse. The goal is to maintain accuracy and ensure that the claim is clean and paid accordingly via CMS Medicare policy. With the editing of claims, you can also limit over under-payments. 

The organizations that aggregate provider claims post clearinghouse process the physician claims through editing solutions before adjudication. The same is applicable for the facility claims with multiple specialists submitting charges on one hospital claim. 

How does CMSPricer Help in Claim Editing?

CMSPricer presents an inexpensive solution for Medicare claims editing. You can analyze claims and eliminate or modify errors with this editing solution when needed. 

The benefit of using this solution is it comes with an edit-only approach accomplishing jobs faster and with an option to scale. CMSPricer also offers a customizability option, enabling users to meet their client’s specifications and also put across analytics behind each claim and edits that fired against the algorithm in the production. 

CMSPricer gives an easy, user-friendly dashboard and also allows its users to customize configurations right on it. They can switch “on/off” specific edits when required, such as configuration forms, part of the CMSPricer portal, etc. Simply put, users like payers, TPAs, auditing firms, PPOs, etc. can self-mage the Medicare claim configurations easily. 

See below the claim edits that CMSPricer, one of the best medical editing solutions, is designed to process:

  • Diagnosis Code Validation
  • Local Coverage Determination (LCD)
  • National Coverage Determination (NCD)
  • Age Edits
  • Gender Edits
  • Outpatient Code Edits (IOCE)
  • Medically Unlikely Edits (MUE)
  • Correct Code Initiative (NCCI)
  • CPT Edits
  • RVU Edits
  • Modifier Edits
  • Advance Benefits Notice of Non-Coverage (ABN)
  • SaaS-based automated claims editing and repricing tool, the CMSPricer performs claim editing 10x faster than the CMS PC Pricer tool. You can also “batch” claims into our system easily, import/export a claim file via an excel bath method for re-pricing so easily with our customizable interface, and easily export the claim results. 

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