CMSPricer Can Help Payers Avoid Rebilling Error-Rigged Medicare Claims

In terms of Medicare claims errors, Medicare Administrative Contractors (MACs) provide a periodic report on the ones they encounter most frequently. These are some examples of error-driven Medicare claims that MACs send to payers.

  • Duplicate claims are made
  • Referring physicians’ primary identifiers are missing or incorrect
  • A POS code that is invalid or inconsistent

If there is missing information, the payment or processing of the claim is not possible. Since this claim cannot be processed, you do not have any appeal rights. If the information on your claim is incorrect, please submit a new claim.

CMSPricer Repricing System

What Causes Medicare Claim Processing Errors?

Payers face challenges processing Medicare claims’ rates due to code complexity, CMS rules that are constantly evolving, and regulatory changes. A payer or their organization would receive a message from a MAC asking for the correction of the errors if there were any compatibility issues with the codes, CMS rules, diagnosis code validation, etc. If such an incident occurs repeatedly, the end-users will not be able to reach the desired outcomes.

Why Does CMSPricer Reduce Denials and Reduce Redundancy in Billing?

CMSPricer offers users an automated way to validate their claims before they are generated and submitted to payers. CMSPricer is a SaaS-based Medicare claims repricing and editing service with a robust and easy-to-use user interface. Through CMSPricer’s API-based editing solution, they can avoid downstream denials and delayed payments.

You can edit your entries multiple times, double-check and generate submission reports until you find the right one using the CMSPricer Medicare claim repricing and editing system.

What is the CMSPricer System’s Editing Process?

You can see what the edits could involve by logging into the CMSPricer system dashboard. The following are some of them:

  • Diagnosis Code Validation
  • National Coverage Determination (NCD)
  • Local Coverage Determination (LCD)
  • Outpatient Code Edits (IOCE)
  • Professional (CMS 1500) and Institutional (UB04) CMS rules
  • Age Edits
  • Correct Code Initiative (NCCI)
  • Medically Unlikely Edits (MUE)
  • Modifier Edits
  • Advance Beneficiary Notice of Non-Coverage (ABN)
  • CPT and RVU Edits

As a result of the editing system, users will easily identify missed revenue opportunities, have a clean claim/first submission rate of more than 98%, as well as other improvements.

CMSPricer’s Medicare Claims Editing Solution: Why Should Payers Use It?

With CMSPricer, you can produce error-free Medicare claims for a multitude of reasons. When working with revenue cycle claims, CMS Pricing is designed to help increase first pass through rates.

As a result, you will not have to rebill erroneous claims, you will be able to reduce accounts receivable days, identify medical necessity issues before claim submission, improve correct coding compliance, and receive real-time notifications of errors that have been identified.

Final thoughts:

Detecting rejections before they reach your EDI clearinghouse will reduce payment denials, speed to revenue, and AR days. This will save you on average 24 days of waiting for rejections and making corrections. In addition to reducing costs, the CMSPrice Medicare Claims Editing Module enables you to rework a rejected professional claim for $10 to $25. Edits are automatically reflected in your billing system: You don’t have to track down CMS changes or learn coding initiatives. APIs are used to push updates automatically.