Edit-Only Approach in CMSPricer Prevents Overpayments & Underpayments While Ensuring Claim Accuracy

By replacing manual processes and centralizing their workflows, third-party administrators can save money by reducing costs. In turn, TPAs can re-price all commercial claims at Medicare rates (Reference Basis Pricing) and rate all Medicare claims based on the Medicare cap. 

SaaS-based Medicare claims repricing platform CMSPricer centralized clinical, financial, and administrative processes to provide TPAs, payers with a competitive edge and ensured cost-effective benefit administration. CMPricer is designed to facilitate electronic claims transmission from providers to TPAs for Medicare repricing, resulting in clean claims ready for submission. 

The most advantage of using CMSPricer for TPAs is it offers an Editing option that allows its users to check and uncheck or switch on or switch off claim parameters to meet the client’s specifications. 

An inexpensive solution, this editing option is intended to help analyze a claim and identify any edits whenever required. While leveraging this solution, it will edit the claim only and not re-price it. 

This edit-only approach is typically a fast and scalable API interface available from CMSPricer. 

This SaaS-based, rule-based platform is aimed at automating workflows. Now with this edit-only approach in it, this engine can also work with the users to design and implement a workflow that meets the client’s specifications. The system is designed to report back to the users regarding the analytics behind each claim and edits that fired against the algorithms in production. 

With this feature integration, the clients can rest assured that the claim will be clean and paid based on the latest CMS Medicare policy. This is also true for hospital claims with multiple specialists submitting charges for the same procedure. These edits prevent overpayments and underpayments while ensuring accuracy. CMS Medicare policy rate schedules indicate that these claims without edits may be overpaid. 

The Following are the Typical Claim Edits that CMSPricer Can 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)

As said, this edit-only feature in CMSPricer allows for customization of configurations to switch on/off specific edits, as and when required. You will see the configuration forms, which are a part of the CMSPricer portal, as providing an easy, user-friendly dashboard that the client can self-manage. 

Also, get claims for editing that you can self-load via an excel batch method, whereas the client can import the claims for editing and easily export the claim results. Most interestingly, the entire process is self-managed and self-served. The system is built to perform the entire process in a matter of minutes and is available 24/7 on the client’s needs and timeline.

Do you want to leverage this edit-only feature of CMSPricer? Click here to connect.