Healthcare prices set by fee-for-service have a direct impact on the prices paid by insurers throughout the health care system. But one of the most significant changes in the health care delivery system in the past few years has been the shift away from traditional FFS payment methods to managed care arrangements. It has been largely driven by the demands of the payers for cost control and a growing provider surplus.
PPOs serve the purpose by representing the form of managed care arrangements. In the PPO settings, payers contract with providers to reprice claims at various rates. Some are based on contractual rates while others are based on the CMS Medicare fee schedules. The scenario shows more control over healthcare while enabling patients to choose networks as they wish. If you check with the fee-for-service pricing method, it computes allowed amounts based on service codes where flexibility is missing.
PPOs are an attractive type of managed care arrangement. The reason is they offer something for everyone. The payer hopes to control costs through discounted fees by leveraging management controls.
How do PPOs Price Medicare Claims?
Compared to manual pricing, the automated pricing of Medicare claims is always preferred. First, it renders precise outputs and streamlines the entire process, thereby enabling payers to carry out more volume of their tasks.
How does the CMSPricer Contract Configuration Module Help?
CMSPricer is a SaaS-based Medicare repricing software. The contract configuration module of CMSPricer is a veritable resource for medical contract solutions offering end-to-end claims configuration services. This module is built to price any claim at any specific rate and easily populate results from spreadsheets so that each provider or facility has a specific assigned rate for each claim and claim type. It includes facilities to identify providers, provider organizations, and their relationships.
What is the Goal?
In doing so, one provider can transfer from one organization to another as of a specific date. It will also allow facilities to maintain multiple fee schedules and their association to provider organizations.
When is This Contract Configuration Tool Essential?
This contract configuration module feature is especially essential when the fee schedules change over time. CMSPricer, one of the most robust CMS contract configuration tools, introduces this module to enable payers to automatically manage a rate payment increase to a provider for 3% on any given day (typically annually), saving them from processing them manually to implement it for the providers and receive accurate rate increases on an annual basis.
The Upshot: Automated Healthcare Configuration Solutions
The contract configuration module in CMSPricer is also geared to support pricing some claims with fee-for-service (FFS) method and various other claim processing with CMS pricing. Users can upload the FFS claims to the system that will automate pricing based on the predetermined FFS loaded schedule.
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