• info@CMSPricer.com
  • support@CMSPricer.com
  • (469) 629-6162

CMS.GOV PCPRICER

The government-based prospective payment frameworks are subject to change almost daily and falling behind these updates greatly increases the risk for inaccuracy, increased audits, costly manual claims reviews, disputes, and time-based fees and penalties. Returning information beyond standard claim pricing details (such as claims errors or edits) will ease provider disputes and reduce inefficiencies caused by inappropriate adjudication and high volumes of pending claims.

Integrating a claims system to a SaaS application through secure technologies (e.g. CMSPricer) enables communication of meaningful information. The unparalleled advantage of solutions that fully leverage SaaS capabilities is addressing compliance headaches through seamless, immediate integration of frequent data updates and providing access to regulatory compliance data before effective dates.

CMS publishes daily transmittals to communicate new or altered policies, rates and other specific modifications. These can include retroactive changes to claims payment rules dating back months or years. If payers must reprocess claims, how do they correct prior payments that are suddenly incorrect? Why does the timing of claims correction matter? Millions of identified under- or overpaid dollars are waiting to be reclaimed by the overpaying payer or the underpaid provider, creating disputes and time-based fees and penalties.

CMS.GOV Website: "The PC Pricer is a tool used to estimate Medicare PPS payments. The final payment may not be precise to how payments are determined in the Medicare claims processing system due to the fact that some data is factored in the PC Pricer payment amount that is paid by Medicare via provider cost reports. A variance between actual Medicare payment and a PC Pricer estimate may exist as there is typically a 3-month lag in quarterly updates to provider data. Likewise, due to the approximate 3-month lag time, the absence of a record for any given provider in the Provider Specific file that accompanies the PC Pricers DOES NOT necessarily imply that the missing provider is not enrolled in Medicare and/or is not eligible for payment under Medicare.”